How is Physiotherapy rehabilitation helping post-COVID-19 patients?

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Question - How is Physiotherapy rehabilitation
helping Post - COVID-19 patients?
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How is Physiotherapy rehabilitation helping
post-COVID-19 patients?
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 has 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?

As per one peer-reviewed study coming out of Rome
reporting results on long-term symptoms of
COVID-19 infection from 143 patients that were
included in the study who were assessed a mean of
60.3 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-19related 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 can
play an important role in the rehabilitation of
patients with COVID-19 who experience limitations
in daily physical functioning.
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How is Physiotherapy rehabilitation helping
post-COVID-19 patients?

• 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.
Hospital patients that have been referred to a
physiotherapist at discharge will receive
transfer information from the hospital.
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.
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 patients
exercise capacity and treatment plan.
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How is Physiotherapy rehabilitation helping
post-COVID-19 patients?
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 patients specific
needs and request for guidance, the
physiotherapist decides whether there is an
indication for physiotherapy. 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
Patients 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.
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How is Physiotherapy rehabilitation helping
post-COVID-19 patients?

• 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.
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How is Physiotherapy rehabilitation helping
post-COVID-19 patients?
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 patients GP.
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