Physical Therapy and Covid-19
Did you know?
Covid can cause systemic inflammation that can lead to respiratory distress, multi-organ failure, coagulopathy (clotting issues), and endothelialitis (inflammation of blood vessel lining for heart, lungs, kidneys, gut, etc); This can look like fatigue, shortness of breath, muscle ache/stiffness, and low blood pressure even after recovering from active infection. Up to 20% of people hospitalized for Covid return to the hospital within 30 days after discharge home, primarily due to difficulty regaining physical function and/or unmet self care needs. The good news is that there is substantial evidence to support our role as physical therapists to fill the gaps in those needs. We can help to provide home assessments, caregiver training, ordering proper equipment, monitoring or guidance for return to function/activity during the crucial 3 months after hospitalization. One study reports that the “provision of home or community based rehabilitation during this critical post discharge period is associated with a 14-82% reduction in downstream hospital readmissions across medical, cardiac, and neurological diagnoses”. Got Grit?
Rehabilitation after COVID-19: an evidence-based approach
COVID-19’s impact arose from its rapid emergence, the number of people needing intensive care, and the lack of prior knowledge of its manifestations. COVID-19 patients presented many clinical problems, including respiratory failure, excessive immunological response and clotting disorders, renal failure and myocarditis. Medical services responded by drawing on evidence, not specifically derived from patients with COVID-19 but directly applicable to their problems. Over time, some techniques, such as lying patients prone to assist breathing and using continuous positive airway pressure, have been found to be more effective than expected. Existing knowledge has been used successfully.
Knowledge of the disease process and which tissues are likely to have been damaged is important in the rehabilitation process. The disease determines both what impairments are likely or unlikely, guiding assessment, the general prognosis and planning of rehabilitation. The whole range of individual problems arising after COVID-19 and their relative frequency is not yet known. Nevertheless, apart from its effects upon the respiratory system, the virus can affect the heart and cardiovascular system,6 the brain directly (encephalitis) and indirectly (eg secondary to hypoxia or vascular thrombosis),7 the kidney and renal function,8 blood clotting9 and the gastrointestinal tract;10 the virus has also been found in semen.11
We therefore have to assume that, after COVID-19, a patient may develop persisting dysfunction of almost any organ system and thus have almost any symptoms and signs. This is similar to the situation with many other disabling conditions, including trauma, systemic lupus erythematosus, diabetes and meningococcal septicaemia. Patients with COVID-19 are more likely to have pre-existing disabling conditions and, in addition, will experience the well-established direct (physical) and indirect (psychological) effects associated with severe illness and a long stay in an intensive care unit.12
There is no specific symptom, or group of symptoms or signs, that indicates the overall severity of the COVID-19 illness. This is in contrast to stroke, for example, where markers such as the National Institute of Health Stroke Scale (NIHSS) score measures, to an extent, the severity of stroke, its prognosis and outcome. The situation with COVID-19 is more like that after trauma, where there is very little relationship between the index of trauma severity – the injury severity score (ISS) – and the need for rehabilitation.
The complexity and variability of the damage caused by COVID-19, coupled with the pre-existing disabling long-term conditions that many patients will have, means that there is no single, COVID-19 specific method to determine the need for rehabilitation. This is actually the situation for almost all diseases, and a generic method for identifying people who might benefit from rehabilitation should be used. Because almost any person with an ongoing disability who has not been seen within a rehabilitation service is likely to benefit,13 the method can be reduced to discovering whether the patient has any ongoing problems or concerns. This includes pre-existing problems.
There is no validated generic checklist for any condition, but Table Table11 shows a reasonable checklist. If the person does not admit to any problems, ideally asked in the presence of a family member, then it is unlikely that a more detailed rehabilitation assessment is needed. If a problem or concern is identified and is not obviously irresolvable or going to resolve without intervention soon, then the patient should be referred to a full, multidisciplinary rehabilitation service. The patient should not simply be referred to a uni-professional service (eg physiotherapy), but referral to a single profession within a multidisciplinary service is satisfactory.