Translating COVID-19 Evidence to Maximize Physical Therapists' Impact and Public Health Response

Justice, Equity, Diversity, and Inclusion-Related Curricular Elements in Entry-Level Physical Therapist Education: A Delphi Study

INTRODUCTION

The purpose of this Delphi study was to determine whether experts in justice, equity, diversity, and inclusion (JEDI) in the field of physical therapy could achieve consensus on the key JEDI-related curricular content topics to be included in entry-level physical therapist education.

REVIEW OF LITERATURE

Inequities exist at all levels of health care for historically underserved populations, including referrals, access, and quality of physical therapy services. The physical therapy field is facing challenges and opportunities in how to best prepare providers to address individual, community, and population health inequities. There is a lack of consensus in physical therapist education regarding essential curricular content related to justice, equity, diversity, inclusion, and antiracism.

SUBJECTS

Eighty-four experts in JEDI in the physical therapy profession were invited through email to participate in the Delphi process.

METHODS

A Delphi survey brought together 39 identified experts in justice, equity, diversity, and inclusion within the field of physical therapy to reach consensus on key JEDI-related curricular topics in physical therapist education. In the first-round survey, participants answered an open-ended question: "What JEDI-related curricular content should be included in entry-level physical therapist education?" The work team coded these free-text responses to populate an initial list of curricular elements. Over 2 subsequent rounds of surveys, the experts came to a consensus on which curricular elements should be addressed within physical therapist education. Nineteen experts completed all survey rounds.

RESULTS

In round I, coding of the expert group's responses generated 61 initial JEDI-related curricular elements. By round III, the group refined the list to 43 curricular elements; 41 of the 43 (95%) elements garnered 94% or higher consensus. The expert group deemed 30 of the elements "entry-level" content and 13 as more "advanced practice" topics.

DISCUSSION AND CONCLUSIONS

Experts had a strong consensus on key JEDI-related curricular elements that physical therapist education programs should include to best prepare providers to improve the health of society. Future scholarship will explore recommendations for how physical therapist education programs might prioritize and implement JEDI-related content.

Physical functioning and health-related quality of life after COVID-19: a long-term perspective case series

The purpose of our study was to monitor the long-term changes in physical functioning and health-related quality of life in individuals who received outpatient rehabilitation after COVID-19. Individuals referred to outpatient rehabilitation for post-COVID-19 physical therapy were assessed before the treatment, at the end of the treatment, and 2 and 6 months after the end of the treatment. The physical functioning was assessed by Barthel Index, Timed Up and Go test, Short Physical Performance Battery test (SPPB), Patient-Specific Functioning Scale (PSFS), and EuroQOL 5D-3L. Friedman's test was utilized to assess changes in the assessments. The proportions of individuals showing variation in performance equal to or greater than the absolute minimal detectable change (MDC) value of the SPPB and PSFS were calculated. Forty-four cases were monitored for 7.3-15.6 months. At baseline, they showed substantial independence in activities of daily living, moderate mobility limitations, and below-average health-related quality of life. Their status significantly improved over time (Friedman's test P = 0.002 to <0.001); post hoc analysis confirmed the improvement of mobility and health-related quality of life at 6-month follow-up relative to the baseline. After accounting for MDC values, 55% meaningfully improved on SPPB and 45% on PSFS, although some worsened (11 and 5%, respectively) and the remaining showed no meaningful change. Despite good independence in activities of daily living and perceived health, individuals surviving the COVID-19 may not have fully recovered their premorbid functioning status seven to 15 months after the infection.

Experiences of physical therapists during the COVID-19 pandemic: an interpretive phenomenological analysis

INTRODUCTION

The COVID-19 pandemic is the most fundamental challenge to the healthcare system in current generations. Physical therapists (PTs), as essential members of the healthcare team, were impacted substantially. Understanding their experiences during this unique and challenging time would help PTs manage the pandemic and future crises in healthcare. It may also reveal professional changes that may persist through the pandemic and beyond.

PURPOSE

To describe the experiences of PTs in the New York metropolitan area during the initial wave of the pandemic.

METHODS

This was an interpretive phenomenological study. Data were collected during 8 focus groups of 2-3 PTs each in August and September 2020 via videoconference. Audio recordings of the groups were transcribed, and data were coded in 3 rounds.

RESULTS

Twenty-two PTs from a range of settings participated. Four themes were identified: (1) Everything was disrupted; (2) It was not safe; (3) It was overwhelming; and (4) There was a professional transformation. In hospitals, participants described chaos, poor communication, and unsafe working environments. In outpatient settings, participants described job instability and challenges adapting to telehealth. As the pandemic progressed inpatient PTs felt safer, gained confidence, and became critical members of interdisciplinary care teams. Outpatient therapists adapted to telehealth and experienced rising caseloads as patients returned to therapy.

CONCLUSION

Physical therapists experienced a variety of challenges during the initial phases of the pandemic. As the pandemic progressed, they redefined practice.

The Role of Physiotherapists in Smoking Cessation Management: A Scoping Review

Physiotherapy (PT) is a profession that includes education and close contact for long periods of time with patients for treatment sessions. Globally, smoking is prevalent and is expected to increase in the next decades; thus, smoking cessation (SC) is an important management strategy to mitigate further escalation. Little is known about PT practice in SC, and therefore, this study aimed to systematically review and discuss the published literature about the role of physiotherapists in smoking cessation management, opinions, and prevalence of SC counselling in physiotherapy practice; and to explore barriers towards smoking cessation counselling within physiotherapy practice. A systematic search was conducted through EBSCO, and articles were included if they assessed the role of PTs in SC management. The databases were searched for studies published between 1 January 1970 to 1 April 2022. Articles were excluded if they did not include PTs, if they did not include assessment of SC management/counselling, if they were not cross-sectional studies, if they were not written in the English language, or if they were conference abstracts. Seven studies were included in the review. The search identified no studies that have investigated the role of PTs in vaping cessation. It was found that PTs are not addressing SC counselling and management enough in their practice. In addition, the search revealed that lack of training, time, and knowledge are the most common barriers against including SC counselling in physiotherapy practice and rehabilitation programs. Exploring possibilities of including SC counselling according to the clinical guidelines is encouraged. Additionally, establishing solutions to overcome barriers against SC counselling as part of physiotherapy practice is essential.

Resilience and its impact on the mental health of physiotherapists during the COVID-19 pandemic in São Paulo, Brazil

OBJECTIVE

To analyze whether resilience modulates the levels of depression, anxiety, stress and the impact of events in physiotherapists who work with COVID-19 patients with those who do not.

METHODS

A cross-sectional study was conducted from August 2020 up to October 2020. A total of 519 physiotherapists were enrolled and divided according to resilience and whether they worked with COVID-19 patients. Volunteers answered sociodemographic questionnaires, rating their depression, anxiety, and stress on a scale (DASS-21). The impact of event scale revised (IES-R) and 14-item resilience scale (14-RS) were also used.

RESULTS

Physiotherapists with low resilience present scores significantly high of depression, anxiety, stress and impact of event compared to the high resilience group (P < .001). Additionally, working with COVID-19 patients also resulted in increased levels of depression, anxiety, stress, and impact of event compared with the NO COVID-19 group (P < .001). These responses were modulated by age, sex, number of absences from work, whether or not personal protective equipment was received, host leadership, and the practice and maintenance of regular physical activity.

LIMITATIONS

The responses to the questionnaires were anonymous and self-administered. We cannot assess whether these people had a previous diagnosis of depression, anxiety and stress.

CONCLUSIONS

Low resilience and work with COVID-19 patients were associated with high levels of depression, anxiety, and stress and worse psychological impacts of events. Several aspects modulate these responses and can contribute to improving the resilience and mental health of physiotherapists who are responsible for the care of COVID-19 patients.

Organization and offer of physical therapy care in response to the COVID-19 pandemic in Brazil

The recovery of people affected by COVID-19 is a process that continues beyond the acute condition of infection by Sars-CoV-2. The impairment of several body systems can cause functional impacts and demand continuous physical therapy assistance both in outpatient care and in Primary Health Care (PHC). In this essay, we seek to discuss the challenges of organizing and offering Physical Therapy assistance in response to the COVID-19 pandemic in Brazil. The analysis was summarized in three dimensions: offering physical therapy assistance in PHC, outpatient care, via telehealth. It is concluded that functional rehabilitation depends on the PHC's response capacity; there is a shortage of rehabilitation services that precedes the pandemic, and may not respond satisfactorily to the demands of the current epidemiological context; it is necessary to articulate the outpatient physiotherapy and PHC teams; although telehealth is a resource and an opportunity to increase the population's access to functional rehabilitation, its use requires caution; the physiotherapist plays a crucial role in the entire COVID-19 care continuum.

Patient Characteristics and Acute PT and OT Utilization During the Initial Surge of COVID-19: A Retrospective Observational Study

OBJECTIVE

To describe the characteristics of patients and investigate the utilization of physical (PT) and occupational therapy (OT) intervention for those with a positive coronavirus disease-2019 (COVID-19) diagnosis compared with other patient populations during the first 6 weeks of the novel coronavirus pandemic.

METHODS

A retrospective, observational study of adult inpatients with a length of stay of 1 or more days at an urban hospital in Detroit, Michigan. Individuals with a COVID-19 diagnosis were compared with a cohort within similar diagnostic categories (respiratory, fever, and sepsis) but without COVID-19. Outcome measures included PT or OT intervention on 1 or more days, the timing of initial PT or OT visit, the average number of visits and units per patient, length of stay, discharge to home, and readmission within 30 days.

RESULTS

Individuals with COVID-19 had lower rates of discharge to home (P = .001), higher rates of readmission within 30 days of hospital discharge (P = .01), increased hospital length of stay (P = .001), and waited an average of 3.1 days longer for therapy evaluations than subjects in the comparison group (P = .001). The percentage of subjects who had one or more PT or OT visits during their hospital stays was comparable between groups. Once therapy was initiated, the average number of visits per patient and dosing of units in 15-minute increments were similar between the 2 groups.

CONCLUSIONS

Patients acutely ill with COVID-19 hospitalized with the virus during the first 6 weeks of the pandemic remained in the intensive care unit and hospital longer than their counterparts without COVID-19 and had a delay in initiation of PT and OT intervention. PT and OT are important members of the care team for patients with the novel coronavirus. Understanding the descriptive characteristics of patients and therapy services during the initial surge could help improve utilization and patient outcomes.

Physiotherapy management for COVID-19 in the acute hospital setting and beyond: an update to clinical practice recommendations

This document provides an update to the recommendations for physiotherapy management for adults with coronavirus disease 2019 (COVID-19) in the acute hospital setting. It includes: physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the use of physiotherapy treatments and personal protective equipment. New advice and recommendations are provided on: workload management; staff health, including vaccination; providing clinical education; personal protective equipment; interventions, including awake proning, mobilisation and rehabilitation in patients with hypoxaemia. Additionally, recommendations for recovery after COVID-19 have been added, including roles that physiotherapy can offer in the management of post-COVID syndrome. The updated guidelines are intended for use by physiotherapists and other relevant stakeholders caring for adult patients with confirmed or suspected COVID-19 in the acute care setting and beyond.

The Aftermath of the COVID-19 Crisis in Saudi Arabia: Respiratory Rehabilitation Recommendations by Physical Therapists

Since late 2019, the number of COVID-19 patients has gradually increased in certain regions as consecutive waves of infections hit countries. Whenever this wave hits the corresponding areas, the entire healthcare system must respond quickly to curb the diseases, morbidities, and mortalities in intensive care settings. The healthcare team involved in COVID-19 patients' care must work tirelessly without having breaks. Our understanding of COVID-19 is limited as new challenges emerge with new COVID-19 variants appearing in different world regions. Though medical therapies are finding solutions to deal with the disease, there are few recommendations for respiratory rehabilitation therapies. A group of respiratory rehabilitation care professionals in Saudi Arabia and international experts have agreed with the World Health bodies such as the World Health Organization (WHO) on the treatment and rehabilitation of patients with COVID-19. Professionals participating in COVID-19 patient treatment, rehabilitation, and recovery formulated respiratory rehabilitation guidelines based on the DELPHI Method, combining scientific research and personal practical experience. As a result, it is envisaged that the number of individuals in the region suffering from respiratory ailments due to post-COVID-19 will decrease. This narrative review and clinical expertise guidelines may give physiotherapists acceptable and standard clinical guideline protocols for treating COVID-19 patients.

Post-COVID-19 Rehabilitation: Perception and Experience of Austrian Physiotherapists and Physiotherapy Students

The rehabilitation needs of COVID-19 survivors are increasingly recognized, with a focus on combating respiratory and neuromuscular dysfunctions. The aim here was to explore the perception of Austrian physiotherapists and physiotherapy students on post-COVID-19 rehabilitation care and to identify barriers for the application of sufficient rehabilitation. We analysed current knowledge and practical skills in respiratory physiotherapy, performing a cross-sectional national survey among physiotherapists working in outpatient settings and physiotherapy students in their last academic year of bachelor-level education in Austria. Out of 255 survey participants, one-third already had inquiries to treat post-COVID-19 patients, and the majority of respondents expected a further increased inflow of patients with rehabilitation needs (64.2%). Only 11.2% of respondents reported feeling sufficiently informed about post-COVID-19 rehabilitation. A total of 68.2% of students and up to 48.1% of physiotherapists favoured a COVID-19-specific adaptation already in the basic academic education, and 74.1% of survey participants indicated interest in attending specific training. Concerning respiratory physiotherapy, our data showed discrepancies between the estimation of the importance of specific examination and treatment techniques and the level of current experience. There is a clear lack of experience in implementing effective device-based respiratory therapy. Our data indicate an urgent need to develop new education and training programs with a focus on the interdisciplinary rehabilitation of patients with post-COVID-19 syndrome.

Immuno-modulation with lifestyle behaviour change to reduce SARS-CoV-2 susceptibility and COVID-19 severity: goals consistent with contemporary physiotherapy practice

Lifestyle-related non-communicable diseases (NCDs) and their risk factors are unequivocally associated with SARS-CoV-2 susceptibility and COVID-19 severity. NCD manifestations and their lifestyle risks are associated with chronic low-grade systemic inflammation (CLGSI). This review supports that immuno-modulation with positive lifestyle change aimed at reducing SARS-CoV-2 susceptibility and COVID-19 severity, is a goal consistent with contemporary physiotherapy practice. Physiotherapists have a long tradition of managing a , thus, managing CLGSI is a logical extension. Improving patients’ lifestyle practices also reduces their NCD risks and increases activity/exercise capacity, health and wellbeing – all principal goals of contemporary physiotherapy. The COVID-19 pandemic lends further support for prioritising health and lifestyle competencies including smoking cessation; whole food plant-based nutrition; healthy weight; healthy sleep practices; and stress management; in conjunction with reducing sedentariness and increasing physical activity/exercise, to augment immunity as well as function and overall health and wellbeing. To support patients’ lifestyle change efforts, physiotherapists may refer patients to other health professionals. The authors conclude that immuno-modulation with lifestyle behaviour change to reduce susceptibility to viruses including SARS-CoV-2, is consistent with contemporary physiotherapy practice. Immuno-modulation needs to be reflected in health competencies taught in physiotherapy professional education curricula and taught at standards comparable to other established interventions.

Apparent Discordance Between the Epidemiology of COVID-19 and Recommended Outcomes and Treatments: A Scoping Review

OBJECTIVE

Many survivors of COVID-19 experience ongoing signs and symptoms affecting multiple body systems that impair function and negatively affect participation and quality of life. The purpose of this review was to identify and synthesize outpatient rehabilitation assessment and treatment recommendations for adults in postacute COVID-19 stages.

METHODS

MEDLINE (Ovid), EMBASE (Ovid), Central, CINAHL, and Scopus were searched from January 1, 2020, to December 7, 2020. Teams of 2 reviewers independently assessed study eligibility and extracted data. All study designs that included rehabilitation recommendations were included. Study design, country, study population, purpose, and rehabilitation recommendations were recorded. Select questions from the Appraisal of Guidelines for Research and Evaluation instrument were used to evaluate the quality of consensus guidelines.

RESULTS

Forty-eight articles fit the inclusion and exclusion criteria (11 systematic reviews, 1 scoping review, 6 original research studies, 4 consensus guidelines, 26 narrative reviews, and editorials/commentaries). Recommended outcomes included exercise tolerance, respiratory function, muscle strength, and activities of daily living or functional independence. Recommended treatments included respiratory rehabilitation, exercise therapy, education, psychological support, activities of daily living and gait training, traditional Chinese medicine, and cognitive and vocational rehabilitation.

CONCLUSION

There were incongruities between what is known about postacute COVID-19 and what was recommended in the literature. Given the relatively large proportion of survivors who experience ongoing symptomatic COVID-19 or post-COVID-19 syndrome, it is important to quickly develop tools for self-management and access to rehabilitation specialists in multidisciplinary teams.

IMPACT

Physical therapists, occupational therapists, and respiratory therapists have an important role to play. Clinicians should focus on epidemiological evidence and emerging information on late sequelae of COVID-19 to inform rehabilitation programming and future research.

The Spread of COVID-19 Among 15,000 Physical Therapists in Italy: A Cross-Sectional Study

OBJECTIVES

The purpose of this study was to explore the prevalence, personal- and work-related exposures, and signs and symptoms among physical therapists during the first wave of coronavirus disease 2019 (COVID-19) in Italy.

METHODS

This cross-sectional, survey-based study collected demographic and exposure data from physical therapists from April to May 2020. All physical therapists working in inpatient and outpatient care in Italy were eligible. A self-administered questionnaire was distributed among all eligible physical therapists to collect (1) demographic characteristics, (2-3) personal- and work-related exposures, and (4) signs and symptoms of COVID-19. Factors associated with a COVID-19-positive nasopharyngeal swab (NPS) were explored through logistic regression models and multivariate methods.

RESULTS

A total of 15,566 respondents completed the survey, with a response rate of 43.3%, achieving high statistical precision (99% CI, 1% type I error). Among physical therapists who received NPS testing, 13.1% (95% CI = 12.1-14.1%) had a positive result, with a peak reached in March 2020 (36%). The top 5 symptoms were fatigue and tiredness (69.1%), loss of smell (64.5%), aches and pains (60.8%), loss of taste (58.3%), and headache (51.1%). No symptoms were reported by 8.9%. Working in a health care institution (odds ratio [OR] = 12.0; 95% CI = 7.8-18.4), being reallocated to a different unit (OR = 1.9; 95% CI = 1.3-2.7), and changing job tasks (OR = 1.6; 95% CI = 1.2-2.3) increased the risk of being COVID-19 positive. In therapists with a confirmed diagnosis of COVID-19, comorbidities were associated with male sex and age older than 51 years.

CONCLUSION

During the first wave in Italy, almost 1 out of 7 physical therapists tested positive on the COVID-19 NPS test. Considering personal- and work-related exposures, health care organizations should adopt prevention measures and adequate preparedness to prevent high rate of infections during future pandemics.

IMPACT

This is the largest investigation about the spread of and main risk factors for COVID-19 in the physical therapy field.

Pelvic Floor Considerations in COVID-19

BACKGROUND

Much of the research and clinical commentary on COVID-19 have been focused on respiratory function. Pelvic floor therapists understand that both respiratory dysfunction and hospitalization can have an impact on pelvic floor function. This clinical commentary provides context as to how the long-term effects of COVID-19 could affect the pelvic floor as well as some generalized treatment considerations.

DISCUSSION

The respiratory diaphragm has an impact on the ability of the pelvic floor to contract and relax in a manner that will allow for both continence and elimination. COVID-19 survivors often have disability in this muscle of respiration that can lead to implications for both overactive and underactive pelvic floor. Commonly, this population is hospitalized for long periods of time, which can have long-term consequences on both bladder and bowel functioning including, but not limited to, incontinence, urinary retention, and constipation. Pelvic floor therapists must be prepared to adjust both their evaluation and treatment methods in consideration of this novel treatment population.

CONCLUSIONS

Because of the pervasive nature of this virus, pelvic floor physical therapists should be a part of the rehabilitation team treating these patients once they have become medically stable.Video abstract with sound available at http://links.lww.com/JWHPT/A36.