Countries all across the world are in various stages of the pandemic with many countries now entering the "day after" COVID-19/Coronavirus phase.

• Many people who have suffered from the effects of this disease might now be at risk of long-term impairment and disability.
• The extent of this impairment and disability is yet unknown, but it is clear from early research that these patients will be in need of rehabilitation/Physiotherapy in all phases of the disease - acute, post-acute, and long-term.
• Physiotherapists are essential to these rehabilitation efforts in all phases to facilitate early discharge, but even more to support and empower patients.

Benefits of Physiotherapy/Rehabilitation in COVID-19 Patients

• Post-Acute COVID-19 Rehabilitation Phase

1. Physiotherapists can be very useful in the rehabilitation of patients as they transition from the acute phase to the post-acute phase
2. The consequences of COVID-19 will be specified in each individual and their rehabilitation needs will be specific to these consequences such as:
   • Long term ventilation
   • Immobilisation-May lead to neck, back pain, and stiffness in the joint
   • Deconditioning- leads to muscle weakness and reduced endurance.
   • Related impairments – respiratory, neurological, musculoskeletal
3. COVID-19 patients will often present with pre-existing comorbidities and that can also affect their functional recovery, the help of physiotherapist may be needed to overcome it.

The transition from the acute to the post-acute phase needs to be supported through service delivery pathways and the multidisciplinary team will be key to this.

COVID-19 Patient Presentation in the Rehabilitation Unit

Conditions that may arise from lengthy ICU-stays include:

Critical Illness Polyneuropathy (CIP)

Critical Illness Polyneuropathy is a mixed sensorimotor neuropathy that may lead to axonal degeneration and studies have shown that patients hospitalised in ICU with ARDS may present with CIP. Critical illness polyneuropathy (CIP) causes several difficulties such as^]:

• Difficulty weaning from mechanical ventilation
• Generalized and symmetrical weakness (distal greater than proximal, but does also include diaphragmatic weakness)
• Distal sensory loss (numbness in fingers)
• Atrophy and weakness in muscles
• Decreased or absent deep tendon reflexes

Critical Illness Polyneuropathy is associated with^]:

• Pain
• Loss of range of motion
• Fatigue
• Incontinence
• Dysphagia
• Anxiety
• Depression
• Post-traumatic Stress Disorder (PTSD)
• Cognitive loss

Critical Illness Myopathy (CIM)

This condition is present in 48 – 96% of patients in ICU with ARDS. It is a non-necrotising diffuse myopathy with fatty degeneration, fibre atrophy and fibrosis.

CIM is associated with:

• Exposure to corticosteroids, paralytics and sepsis.

It has a similar clinical presentation to CIP but with more proximal weakness and sensory preservation. Patients recover more completely from myopathies than polyneuropathies, but with both conditions, there are long term consequences to consider such as:

• Weakness
• Loss of Function
• Loss of Quality of Life
• Poor Endurance

Post Intensive Care Syndrome (PICS)

Characteristics of PICS include:

• Cognitive Impairments/problems
  • Memory
  • Attention
  • Visuo-spatial
  • Psychomotor
  • Impulsivity
• Physical Impairment/Problems
  • Dyspnea/ Impaired pulmonary function
  • Reduced inspiratory muscle strength
  • Pain
  • Sexual dysfunction
  • Impaired exercise tolerance
  • Neuropathies
  • Muscle weakness/Paresis
  • Poor upper extremity and grip strength
  • Poor knee extension
  • Severe fatigue
  • Low functional capacity

The neuromuscular complications from PICS often result in poor mobility, falls and even quadriparesis.

How can we help you after COVID-19

A randomised controlled trial from China implemented a respiratory rehabilitation program consisting of 2 sessions of 10 minutes per week for 6 weeks post-discharge from acute care. The study results showed a significant improvement in respiratory function, endurance, quality of life and depression. The respiratory rehabilitation programme included respiratory muscle training with a positive expiratory pressure device, cough exercises, diaphragmatic training, chest stretching and pursed-lip breathing.

Assessment:

• Muscle and joint range of motion
• Strength testing
• Balance
• Exercise capacity – assess with the 6-minute walking test (continuous oxygen saturation monitoring included)
• Cardiopulmonary exercise testing
• Activities of Daily Living (ADL)

Clinical Management for COVID-19 patients:

• Implement clinical management guidelines and protocols of care related to COVID-19 patients based on the best available evidence
• Adaptable rehabilitation resources for COVID-19 patients who experience ongoing respiratory and physical deconditioning should be available
• These may include:
  • Exercise programs with graded exercises
  • Pacing strategies
  • Behavior modification
  • Advice on positioning
• Recognition of red flags such as signs of medical deterioration
• Implement systems for tracking COVID-19 patients and remote-follow-up
• Implement referral pathways and develop contact lists for services required by COVID-19 patients

At ACT Physiotherapy and Health Services our professionals are trained and educated in the post covid recovery program, they can help you with any of your needs regarding making your functional life better.