In the past year of COVID-19, health care teams around the world have provided care to many patients in various stages of the disease. But what is the role of a physical therapist in this health care crisis? Here, I highlight the key aspects to providing quality, evidence-based physical therapy to individuals with COVID-19 encompassing care in the ICU to home health.
Before we begin, it is critical to understand that physical therapy should be a part of the plan of care for individuals with COVID-19. Research has shown that physical therapy could shorten the hospital admission time by over 20%! Therefore, it is important to advocate for physical therapy services if you or a loved one have been diagnosed with the disease.
Patients in Acute Care and Intensive Care Units
Individuals in this stage are referred to individuals who have “severe COVID” or are medically unstable. A major symptom of COVID is having sputum or “phlegm” restricting the ability to breath and creating irritation of the airways. To address this, the use of diaphragmatic breathing and position changes are crucial. These techniques can assist with removing irritants from the airway and promote more efficient breathing. Individuals in this stage should also be encouraged to work on transfers from the bed to chair and short duration walks less than five minutes to promote mobility and reduce the effects of joint stiffness.
Physical therapy should not be performed if the patient has a fever greater than 100.4° F, resting heart rate is above 120 bpm, or their blood pressure is <90/60 mmHg or >140/90 mmHg. Please see your consulting physician if you or a loved one have concerns whether or not to participate in physical therapy.
It is always important to observe your patient and the ICU is no exception. Since individuals are isolated for long periods of time, they may develop ICU delirium. According to research, nearly 50-90% of all individuals who are in the ICU attain delirium. This is further exacerbated by severe illness and reduced oxygen reaching the brain. Signs of delirium include sudden changes in attention, especially worsening at night, impaired consciousness, and altered sleep schedules.
Transitioning to a Stable or Isolation Room
Following a stay in the ICU, individuals are often weak, and their endurance is reduced. This is known as Post Intensive Care Syndrome (PICS). Before sending patients home, individuals are often sent to isolation rooms to help regain strength and ensure they are safe to be home. Therefore, using resistance training through sitting and standing exercises can help assist the patient in building strength so that they can return home. Some exercises include sitting leg kicks, straight leg raises, marching, and balance exercises. Physical therapists will also conduct gait training and encourage three walks a day for 10 minutes each. Gait training can assist in increasing breathing capabilities, build endurance, and is a functional activity that is used daily.
Individuals who have a decrease in SpO2 by 4% with activity and who are unable to keep their balance should be deferred from physical therapy for the day unless cleared by the overseeing physician.
Outpatient and Home Health
We have now made it through the hospital and have returned home. It is common for individuals to continue physical therapy outside the hospital through either outpatient or home health services. At this time, physical therapists will continue to encourage walking by increasing the duration. These walking bouts are built up to 15 minutes, two times a day. Physical therapists also help patients with daily functions that are difficult for them such as transitioning from sit to standing positions or reaching activities such as grabbing a cup from a cupboard. During this time, it is important for the patient to frequently check their oxygen saturation. Research is showing that individuals who frequently checked their oxygen saturation had a better understanding of how their illness was progressing and could communicate with their physical therapist and physician to create a more effective plan of care.
Patients with a resting heart rate over 120 bpm or a drop in blood pressure by over 20 bpm should not undergo physical therapy that day unless specified by physician.
Symptoms and Conditions to Watch For
Recent literature suggests that individuals who are frail are more likely to have adverse effects from a COVID diagnosis. In fact, those who were frail were nearly seven times more likely to require advanced care after being released from the hospital. Research also indicates that using the Clinical Frailty Scale predicts disease progression better than age and comorbidities. As physical therapists, the CFS is a common tool that can help assist us with treatment and plan of care for individuals diagnosed with COVID.
Individuals who still present with symptoms over a prolonged period have been termed “long haulers.” These patients often have continued difficulty breathing, impaired taste and smell, and heart palpitations that last weeks and even months after their initial infection. Physical therapy can help these individuals cope with their symptoms and provide exercises to minimize their effects. Although there is not a specific way to treat long haulers syndrome, it is a topic that is being heavily researched.
Physical therapy plays a vital role in the recovery of patients with COVID-19. Physical therapists should be involved in the patients care as early as possible to increase breathing efficiency, increase endurance and strength, and reduce the length of stay in the hospital. As always, clear communication with other health care professionals can help bolster care and lead to better outcomes for the patient. For more information, visit the Des Moines University Physical Therapy Clinic website or call 515-271-1717.