Physiotherapy rehabilitation after COVID-19

At the beginning of 2020 we were confronted with a new SARS virus, SARS-CoV-2, also known as COVID-19 or the Coronavirus. Little did we know what impact this virus would have on patients, our healthcare systems and our societies in general. The virus spread quickly and the Corona virus disease rapidly developed into a pandemic.

At the start, all focus was on the treatment of hospitalised, acute and severely ill patients. Now that the first surges of acute cases of COVID-19 patients have subdued we have to deal with the aftermath. We are discovering that patients that have successfully recovered from the disease are suffering from short- and long-term effects caused by the disease. The treatment of these effects requires a great deal of effort and an increase in rehabilitation needs. Physiotherapists will be essential in providing these rehabilitation services.

 

What are the most common effects on patients that have recovered from the disease?

Although social media is flooded with stories from people suffering from ongoing effects such as fatigue, muscle weakness, dyspnoea and decreased quality of life, so far not much evidence has been published on the topic. There is one peer-reviewed study coming out of Rome reporting results on long-term symptoms of COVID-19 infection.¹ 143 patients that were included in the study were assessed a mean of 60.3 (SD, 13.6) days after onset of the first COVID-19 symptom; at the time of the evaluation, only 18 (12.6%) were completely free of any COVID-19–related symptom, while 32% had 1 or 2 symptoms and 55% had 3 or more. None of the patients had fever or any signs or symptoms of acute illness. Worsened quality of life was observed among 44.1% of patients. A high proportion of individuals still reported fatigue (53.1%), dyspnoea (43.4%), joint pain, (27.3%) and chest pain (21.7%).

 

The physiotherapist’s role in rehabilitation of post-COVID-19 patients - Position statement KNGF (Dutch Royal Society for Physiotherapy)

In the position statement the Dutch Royal Society for Physiotherapy released with regard to recommendations in post-COVID-19 patients, they state that:

The physiotherapist can play an important role in the rehabilitation of patients with COVID-19 who experience limitations in daily physical functioning.” The statement, which was first released in May 2020, can be found on the WCPT website as part of their 2020 World PT Day information resources.² ³

 

First six weeks after hospital discharge/ or symptom-free after out of hospital COVID-19 experience 

Post-COVID-19 patient referral 

Patients that have been discharged from the hospital often receive the advice to gradually increase their activities of daily living, and are given functional physical exercises to perform at home.  According to the statement, hospital patients that have been referred to a physiotherapist at discharge will receive transfer information from the hospital. In some cases, the patient will be contacted approximately 2 weeks after discharge and will be referred, if necessary, after assessment of their daily functioning. Non-hospital patients are mainly referred to a physiotherapist by their GP. 

 

Post-COVID-19 patient  assessment by the physiotherapist – first consultation

The recommendations foresee that the patient is contacted within the first 2 weeks after hospital discharge or after symptoms have subdued. This first consultation is done by phone or video calling and aims to assess the perceived limitations in physical functioning.  As during the first six weeks after discharge referred patients have not yet undergone an exercise test and / or a function test*, the therapist must determine the patient’s condition in a different way. The positioning statement foresees the use of all domains of the WHO International Classification of Functioning, Disability and Health (WHO-ICF) model.   Clinical outcome measures used are the following:  

• Patient Specific Functioning Scale (PSFS)
• Before, during and after physical activity oxygen saturation and heart rate frequency
• Before, during and after physical activity,  the Borg Scale CR10 for Shortness of Breath and Fatigue

It is also essential to take into account if a patient has been admitted to the ICU and is showing symptoms of Post Intensive Care Syndrome (PICS) as these patients usually have very low exercise tolerance. Another important factor is to check for the existence of comorbidities acquired prior to or from COVID-19, including possibly affected organs. Based on the obtained information from other health care providers and the patient, together with the patient’s specific needs and request for guidance, the physiotherapist decides whether there is an indication for physiotherapy. 

* Internationally, the organisation of healthcare and clinical follow-up is organised differently. In some countries, such as the Netherlands, most patients receive a medical follow-up in the hospital after approximately 6 weeks of discharge. During that appointment physical functions, physical activity and performance levels are assessed resulting in more information for the physiotherapist to determine patient’s exercise capacity and treatment plan.

 

Post-COVID-19 patient with indication for physiotherapy

Those patients, that have received an indication for physiotherapy, experience reduced functional capacity and/or reduced physical activity levels. To gradually increase their activity of daily living and physical functioning the physiotherapist will provide them with guidance and instructions for specific exercises and will monitor the progress made. To minimise risk of dangerous desaturations and overload:  

• Patient’s oxygen saturation should be measured prior to, during and after exercise or physical activities (lower limit during rest should be 90% and during exercise 85%)
• Patients should only perform physical exercises in the home situation with prescribed training parameters regarding frequency, intensity, time/duration and type  

For patients that may have ICU-acquired weakness (ICU-AW) and experience PICS the recommendation is to refer them (via their GP) to a rehabilitation centre, as the risk of overload is high.  

 

Six weeks after hospital discharge/ or symptom-free after out of hospital COVID-19 experience

Post-COVID-19 patient physical functioning follow up

In some hospitals, patients will visit a medical specialist (e.g. pulmonologist, internal medicine, cardiologist…) six weeks after discharge. They will undergo additional lung and heart function assessment and exercise testing. The test results will determine current physical functioning.  The information will help the physiotherapist to prescribe more specific exercises and guide patients based on their needs and goals. Treatment goals may aim at further improvement of activities of daily living, increase physical activity levels and/or capacity to exercise, e.g. muscle strength and exercise tolerance. To evaluate current and set new or adjusted treatment goals the use of the following clinical outcome measures are recommended:

• Patient Specific Functioning Scale (PSFS)
• Short Physical Performance Battery (SPPB)
• Grip strength (with a hand-held dynamometer if available). 
• Oxygen saturation (SpO2) and heart rate frequency (HR) measurement prior to, during and after exercise. 
• Borg Scale CR10 for Shortness of Breath and Fatigue prior to, during and after exercise. 
• Pedometer / accelerometer, to assess physical activity levels. 
• Six Minute Walk Test (6MWT), to assess exercise capacity.

 

Post-COVID-19 patient goals physiotherapy

The goal of the physiotherapy treatment is to enable the patient to further increase physical activity and improve capacity to exercise. It seems reasonable to assume that training principles, such as those used with patients with chronic lung diseases can be applied in post-COVID-19 patients. When test results show no severe restriction or risks, training frequency, intensity, time/duration and type of exercises may be gradually increased. 

To minimise risk of dangerous desaturations and overload, oxygen saturation should be measured prior to, during and after exercise. If patients do not show any signs of desaturation during physical activity and exercise in the first 2 weeks of increased exercise intensity, than intensive SpO2 monitoring is not indicated any longer.  Exercise prescription should focus on the formulated treatment goals, they should be based on current physical functions and activity levels of the patient.  

When identified limitations cannot be resolved within the field of physiotherapy, the patient might need to be referred to other health care disciplines; in this, the physiotherapist has a signalling function and always keep in close contact with the patient’s GP. 

 

Conclusion

Although many questions are still unanswered, time and experience will help us identifying the specific needs of the post-COVID-19 patient within the field of physiotherapy. The position statement of the Royal Dutch Society for Physiotherapy is definitely a good starting point. The importance of sharing experiences within your local and international physiotherapy communities will help finding new insights and tailor made treatments for the post-COVID-19 patient. 

 

¹ Persistent Symptoms in Patients After Acute COVID-19 – Angelo Carfi, MD; Roberto Bernabei, MD; Francesco Landi, MD, PhD; for the Gemelli Against COVID-19 Post Acute Care Study Group - JAMA. 2020;324(6):603-605. doi:10.1001/jama.2020.12603 ² KNGF position statement: Physiotherapy recommendations in patients with COVID-19. Royal Dutch Society for Physiotherapy (KNGF) ³ WPTD2020_InformationSources.pdf (https://world.physio/sites/default/files/2020-07/WPTD2020_InformationSources.pdf)