Could Physical Therapy Interventions Be Adopted in the Management of Critically Ill Patients with COVID-19? A Scoping Review

Comparison of Clinical Characteristics and Mortality Outcome in Critical COVID-19 Patients Infected with Alpha and Omicron Variants

Objective

Early reports have indicated that the Omicron variant of coronavirus disease 2019 (COVID-19) may be associated with low mortality. However, the mortality rate of critical patients in Taiwan with COVID-19 caused by different variants has not been well described.

Methods

This retrospective cohort study was conducted at the Linkou Branch of Chang Gung Memorial Hospital, Taiwan, from April 2020 to September 2022. Critically ill patients who had confirmed SARS-CoV-2 infection and were on mechanical ventilation (MV) were enrolled. Demographic data, laboratory results, and treatment information were collected and analyzed. In addition, clinical outcomes for different SARS-CoV-2 variants were analyzed.

Results

This study included 110 critical patients with COVID-19 who required intubation and intensive care unit (ICU) admission. Among these patients, 46 (41.8%) required intensive care during Alpha predominance period and 64 (58.2%) during the Omicron predominance period. The Alpha group had a higher body mass index, had a longer ICU stay, and included more patients with acute respiratory distress syndrome, and the Omicron group included more active smokers, had more comorbidities, had worse initial laboratory data (including higher white blood cell counts, prothrombin time [PT], activated partial prothrombin time, blood urine nitrogen levels, and creatine levels), and had higher in-hospital mortality rates (40.6% vs 15.2%, p = 0.004). The independent risk factors for in-hospital mortality, were Charlson Comorbidity Index (CCI) ≥ 3 and higher PT and creatine levels.

Conclusion

Our study discovered that CCI ≥ 3, elevated serum creatine levels, and prolonged PT were independently associated with a high mortality rate in patients with critical COVID-19. Patients with those risk factors may require intensive monitoring during their treatment course.

Psychophysiological Adaptations to Exercise Training in COVID-19 Patients: A Systematic Review

Introduction

Many COVID-19 patients display adverse symptoms, such as reduced physical ability, poor quality of life, and impaired pulmonary function. Therefore, this systematic review is aimed at evaluating the effectiveness of physical exercise on various psychophysiological indicators among COVID-19 patients who may be at any stage of their illness (i.e., critically ill, hospitalized, postdischarge, and recovering).

Methods

A systematic search was conducted in PubMed, Scopus, ScienceDirect, Web of Science, and Google Scholar from 2019 to 2021. Twenty-seven studies, which assessed a total of 1525 patients, were included and analysed.

Results

Overall, data revealed significant improvements in the following parameters: physical function, dyspnoea, pulmonary function, quality of life (QOL), lower limb endurance and strength, anxiety, depression, physical activity level, muscle strength, oxygen saturation, fatigue, C-reactive protein (CRP), interleukin 6 (IL-6), tumour necrosis factor-alpha (TNF-α), lymphocyte, leukocytes, and a fibrin degradation product (D-dimer).

Conclusions

Physical training turns out to be an effective therapy that minimises the severity of COVID-19 in the intervention group compared to the standard treatment. Therefore, physical training could be incorporated into conventional treatment of COVID-19 patients. More randomized controlled studies with follow-up evaluations are required to evaluate the long-term advantages of physical training. Future research is essential to establish the optimal exercise intensity level and assess the musculoskeletal fitness of recovered COVID-19 patients. This trial is registered with CRD42021283087.

Knowledge, Attitude, and Practice of Physiotherapists in COVID-19 ICUs: A National Survey

Background

COVID-19 belongs to the beta-corona cluster that spreads enormously via aerosols. Physiotherapists must be knowledgeable about the symptoms, mode of transmission, risk mitigation strategies, and practice guidelines for COVID-19.

Objective

This study aimed to assess physiotherapists' knowledge of COVID-19 guidelines, their attitude toward this new evolving field, and their practice routines in India's COVID-19 ICUs.

Methods

It was a cross-sectional study. A total of 600 questionnaires were distributed through e-mail and WhatsApp to physiotherapists using Google Forms between February 2022 and January 2023. The questionnaires consisted of demographics and 23 questions in three sections about the knowledge, attitude, and practice of physiotherapists working in the COVID-19 ICU. Data analysis was carried out using Jamovi.

Results

A total of 136 responses were obtained from 18 states of India. Of 136 participants, 89 were female (65.4%) and 47 were male (34.6%). The highest level of qualification was BPT (n = 69 (50.7%)), followed by MPT (n = 62 (45.6%)) and Ph.D. (3 (3.7%)). The knowledge about COVID-19 guidelines is fair. Only 21.3% of the physiotherapists received training before being deployed in COVID-19 ICUs, and the CARP protocol was well known by only as few as 10.3%. The criteria advised for close monitoring of patients during treatment was aware by 29.4%. Most physiotherapists have a good attitude toward treating COVID-19 patients; 70.63% strongly agree that physiotherapy is vital in these patients despite the risk of self-exposure, and 64.7% agree that physiotherapy should be initiated during all phases of COVID-19. Physiotherapists follow good practices for COVID-19 patients in the ICU, which is as per the guideline recommendation.

Conclusion

Physiotherapists working in COVID-19 ICUs have a fair knowledge of the existing physiotherapy guidelines for COVID-19, and they exhibit good attitudes and practice patterns.

Early physiotherapy management of patients with Covid-19 admitted to a university hospital in Norway (March 2020 to July 2021)

AIM

The aim of this retrospective observational study was to describe the scope of physiotherapy, the population and the physiotherapy management of Covid-19 patients referred to physiotherapy at a university hospital in the period from March 2020 to July 2021.

METHOD

A descriptive observational study with access to data from a quality register, which contains clinical data of all patients admitted with Covid-19 to a university hospital in Norway. Data was obtained from electronic data sheets, where daily parameters for physiotherapy treatment were registered.

RESULTS

In total, 729 Covid-19 patients were admitted during this period. Of these, 507 (69.6%) received treatment by a physiotherapist (3510 sessions). The physiotherapy treatments were performed on intensive care units (ICU) (50%), intermediate care units (11%) and general medical units (39%), respectively. Patients were mainly treated during the day (98.5%) and 21% of the sessions were given on weekends or holidays. Within the 3510 sessions, 9459 interventions were performed in total (one to seven interventions per session). The most common intervention provided was positioning (35.4%). The most common interventions in medical units and intermediate care units were training with a positive expiratory pressure device (17.3% and 15.9% respectively), and techniques for reducing work of breathing (13% and 15% respectively). The most common intervention in the ICUs was passive mobilization (21.3%), mostly in combination with positioning, manual techniques and/or airway clearance.

CONCLUSION

This study provides characteristics of, and experiences with early physiotherapy, in sequentially hospitalized patients at a university hospital in Norway.

Negative impact of behavior restriction amidst a clustered COVID-19 infection on immobility syndrome in older patients negative for COVID-19: report from a chronic care hospital in Japan

Previous studies have reported on associations between immobility syndrome and the COVID-19 pandemic. However, little is known about the aggravation of this syndrome in older patients negative for COVID-19 infection amidst behavior restriction due to a clustered COVID-19 infection. Patients hospitalized one month before a clustered COVID-19 infection occurred in our hospital were recruited. Rehabilitation therapy was suspended for 25 days during behavior restriction. The ability of daily living of the patients was evaluated with the functional independence measure and Barthel index. Chronological changes in the functional independence measure and Barthel index scores were evaluated monthly, beginning one month before the clustered COVID-19 infection to one month after re-initiation of rehabilitation therapy. Patients with minimum scores in the functional independence measure (18) and Barthel index (0) prior to the clustered COVID-19 infection were excluded. Functional independence measure scores of 73 older patients and the Barthel index scores of 48 patients were analyzed. The mean total functional independence measure score amidst the behavior restriction significantly changed from 36.3 to 35.1 (p = 0.019), while statistical significance was not detected in the mean motor subtotal (from 21.6 to 20.9 with p = 0.247) or cognitive subtotal functional independence measure scores (from 14.6 to 14.2 with p = 0.478). During the behavior restriction, the mean Barthel index scores declined from 25.8 to 23.2 without statistical significance (p = 0.059). Behavior restriction due to a clustered COVID-19 infection may aggravate immobility syndrome in older patients who are negative for COVID-19.

Early physiotherapy and chest wall oscillation in patients with COVID-19 disease at the intensive care unit: a pilot clinical trial

Over the past few years, the early mobilization and rehabilitation of patients in the intensive care unit (ICU) has drawn a lot of interest from the clinical and scientific communities. An interdisciplinary team treating patients suffering from serious conditions should include physiotherapy. Additionally, physiotherapy is utilized to treat and prevent the side effects of extended immobility or sleep, as well as to improve respiratory function. The purpose is to improve residual functionality; to avoid new and repeated hospitalizations; to improve health and quality of life. Exercises for the entire body (including early in-bed cycling), specialized breathing exercises, chest mobilization, relief help, drainage postures, vibration, verticalization, and passive movements are all crucial components of COVID-19 physiotherapy. Our goal was to evaluate the changes of functional condition of patients with COVID-19 in the acute stage using different physiotherapy methods: complex measures against mono therapy. In the research, 28 subjects (15 men and 13 women) were involved. A total of 84 physiotherapy procedures were performed. In the first group, breathing exercises and chest wall oscillation were applied, in the second group – only chest wall oscillation. Respiratory physiotherapy (breathing exercises) plays an important role in reducing and preventing respiratory complications in COVID-19 patients treated at ICU. Early mobilization and chest wall oscillation are beneficial in COVID-19 patients. We note that we are the first to conduct an evidence-based study of physiotherapy in intensive care with COVID-19 patients. We hope that our pilot clinical trial gives opportunity to future researches.

Effectiveness of Pulmonary Rehabilitation among COVID-19 Patients: A Systematic Review and Meta-Analysis

Background: Many COVID-19 patients presented with detrimental features, such as impaired respiratory function, physical capacity, and overall poor quality of life. The present study evaluates the effectiveness of pulmonary rehabilitation on COVID-19 patients. Methods: We searched PubMed, Scopus, ScienceDirect, and Google Scholar from 2019 to 2021. The protocol was registered in PROSPERO with the registration number CRD42021273618. We performed statistical analyses via random effects and expressed the outcomes as standardized mean difference (SMD) for continuous variables, with 95% confidence intervals (CI). Results: We included six trials involving 432 patients. The primary outcome showed a significant improvement in physical function (SMD 0.83, 95% CI −0.58 to 1.09; p < 0.001; four trials, 266 participants; high-quality evidence). There was significant difference in anxiety (SMD −0.80, 95% CI −1.23 to −0.37; p = 0.003), physical activity intensity levels (SMD −1.27, 95% CI −2.23 to −0.32; p = 0.009), sleep quality (MD −0.05, 95% CI −0.83 to −0.16; p = 0.004), peripheral muscle performance of lower limbs (SMD 0.90, 95% CI −0.60 to 1.20; p < 0.001), and dyspnoea outcomes (SMD −0.55, 95% CI −0.87 to −0.23; p = 0.007). Conclusions: Pulmonary rehabilitation is an effective adjuvant therapy that minimizes COVID-19 severity in the intervention group compared to the conventional treatment. The findings of this study will need to be considered in the framework of the clinical outcome as observed in the intervention outcome. Additionally, safer data on guideline rehabilitation would be needed to examine whether pulmonary rehabilitation would be a fruitful intervention to reduce COVID-19 severity.

Breathing exercises versus strength exercises through telerehabilitation in coronavirus disease 2019 patients in the acute phase: A randomized controlled trial

OBJECTIVE

To compare the effectiveness of two different exercise-based programs through telerehabilitation in patients with coronavirus disease 2019.

DESIGN

Randomized, controlled, parallel, double-blinded, three-arm clinical trial.

SETTING

Patients' homes through telerehabilitation devices.

SUBJECTS

Subjects with coronavirus disease 2019 in the acute phase.

INTERVENTIONS

Subjects were divided into three groups: breathing exercises group, strength exercises group or no treatment/control group.

MAIN MEASURES

We analysed visual analogue scale for fatigue, 6-minute walking test, 30-seconds sit-to-stand test, multidimensional dyspnoea-12 questionnaire and Borg scale at baseline and 14 days later.

RESULTS

From 93 subjects recruited, 88 were enrolled, and 77 patients (mean [SD] age 39.40 [11.71]) completed the 14-days intervention and were included in the analysis: 26 in strength exercises group, 29 in breathing exercises group and 22 in control group. The intergroup analysis shows significant differences between the study groups and control group in all variables (p < 0.05); Borg scale, multidimensional dyspnoea-12 questionnaire (pre-post intervention score: strength exercises group: 7.85 [6.82] - 4.54[4.82], breathing exercises group: 11.04 [6.49] - 5.32 [3.63], control group: 10.27 [6.49] - 10.59[6.58]), visual analogue scale for fatigue, 6-minute walking test and 30-seconds sit-to-stand test (pre-post intervention score: strength exercises group: 12.19 [4.42] - 13.58 [5.37], breathing exercises group: 11.18 [3.42] - 12.79 [4.00], control group: 10.45 [2.15] - 9.86[1.88]). The greatest effect sizes were found in the variables Borg Scale (R² = 0.548) and multidimensional dyspnoea-12 questionnaire (R² = 0.475).

CONCLUSIONS

Strength exercises group and breathing exercises group obtained significant improvements in fatigue, dyspnoea, perceived effort, and physical state, compared to control group, although the greatest benefits were found for dyspnoea and aerobic capacity in breathing exercises group.

Gefühlte und reale Arbeitsfähigkeit von Patient*innen mit Post-COVID Symptomatik nach mildem Akutverlauf: eine Analyse des Rehabilitation Needs Questionnaire (RehabNeQ)

Hintergrund Das Beschwerdebild der Folgeerscheinungen, die nach einer COVID-19-Erkrankung auch nach Monaten existieren können, wird immer deutlicher: das Post-COVID-Syndrom. Neben verschiedenen Symptomen können auch funktionellen Zusammenhänge bestehen, die die Arbeitsfähigkeit einschränken. Derzeitige Untersuchungen gehen von 10% der Infizierten aus, die dies betrifft. In Deutschland würde dies nach aktuellen Zahlen 380 000 Menschen betreffen. Das Ziel dieser Analyse war es zu zeigen, wie sich die reale und gefühlte Arbeitsfähigkeit bei Patient*innen mit Post-COVID Syndrom darstellt.

Methode Der Rehabilitation Needs Questionnaire wird routinemäßig bei Patient*innen mit Post-COVID-Symptomatik bei Vorstellungen in der Medizinischen Hochschule Hannover bzw. dem Universitätsklinikum Jena ausgefüllt. Es erfolgte eine deskriptive Analyse der Fragebögen ab April 2021 unter besonderer Berücksichtigung der Arbeitsfähigkeit. Ausgeschlossen wurden Patient*innen, die nicht im arbeitsfähigen Alter waren, oder bereits vor der COVID-19-Infektion arbeitsunfähig.

Ergebnisse 75 von 81 Fragebögen wurden im entsprechenden Zeitraum von einer Stichprobe im arbeitsfähigen Alter in die Auswertung mit einbezogen (68% von Frauen, 32% von Männern). Das Durchschnittsalter lag bei 42,5 Jahren, die Zeit seit der Infektion im Mittel bei 3 Monaten. 44 der 75 Personen (58,7%) waren zum Zeitpunkt der Befragung arbeitsfähig. Die empfundene Arbeitsfähigkeit wurde im Schnitt mit 5,1 von 10 möglichen Punkten angegeben. Frauen zeigten hier durchschnittlich 6,2 Punkte und Männer 4,7 Punkte. 59,1% (n=26) der Befragten gaben Schwierigkeiten beim Erhalt von notwendigen Therapien an. 31 (41,3%) Personen waren zum Zeitpunkt der Befragung aufgrund der POST-COVID-19-Erkrankung arbeitsunfähig. Das mittlere Alter der Gruppe lag bei 46,6 Jahren. 16 (51,6%) der 31 Proband*innen gaben an ununterbrochen seit der Infektion arbeitsunfähig zu sein. Schwierigkeiten beim Erhalt von notwendigen Therapien hatten in dieser Gruppe 64,5% (n=20).

Diskussion Die Rate derer, die nach einer COVID-19-Erkrankung auch nach Monaten noch arbeitsunfähig sind, ist hoch. Notwendige therapeutische Maßnahmen stehen entweder in nicht genügender Anzahl zur Verfügung oder werden trotz entsprechender Indikation nicht ausreichend verordnet. Weitere Untersuchungen sind notwendig, um die Wirksamkeit von Therapien zu belegen und welche Barrieren zur Rückkehr an den Arbeitsplatz bestehen. Die Auswirkungen können bei weiter steigenden Fallzahlen noch über Jahre hinweg Einfluss auf die Wirtschaftskraft des Landes haben.

Physical Function, Cognitive Function, and Daily Activities in Patients Hospitalized Due to COVID-19: A Descriptive Cross-Sectional Study in Sweden

An estimated 14–20% of people infected with COVID-19 require medical care. The aim of the present study was to evaluate physical function, cognitive function, and daily activities in patients hospitalized due to COVID-19, and to investigate differences depending on age and admission to the intensive care unit (ICU). This prospective descriptive cross-sectional study included a consecutive sample of 211 patients (mean age 65.1 years, 67.3% men) hospitalized due to COVID-19 in Sweden. Data regarding physical function and daily activities were collected in hospital from July 2020 to February 2021. The average length of hospital stay was 33.8 days, and 48.8% of the patients were admitted to the ICU. Physical function (grip- and lower body strength) was reduced in both groups, and significantly more in the older group, ≥65 years old, compared to the younger. Furthermore, the older group also had significantly less ability to perform activities in daily life, and had significantly reduced cognitive function as compared to the younger age group. In patients treated in the ICU, physical impairments as well as the activity level were significantly more pronounced compared to patients not treated in the ICU. Patients hospitalized due to COVID-19 are physically impaired, have mild cognitive impairments, and have difficulties performing daily activities. The findings in this study indicate the need for out-patient follow-up and rehabilitation for patients hospitalized due to COVID-19, especially in older patients and patients treated in the ICU.

Declined Activities of Daily Living as Immobility Syndrome in an Uninfected Elderly Patient Amidst a Cluster of COVID-19 Infections

Although coronavirus disease 2019 can cause immobility syndrome in the patients positive for coronavirus disease 2019 and the survivors of coronavirus disease 2019, it is not described in elderly patients who are not positive for coronavirus disease 2019.

A 90-year-old female with motor weakness of the lower extremities was admitted in the chronic care hospital. She had rehabilitation therapy for independent ambulation and toilet activities. Though she complained of irregular pulse related to atrial fibrillation during rehabilitation therapy, the symptom disappeared within a few minutes. Her ambulation and toilet activities became better with rehabilitation therapy. However, three weeks after initiating rehabilitation therapy, a cluster of coronavirus disease 2019 infections occurred. The patient was not infected, but rehabilitation therapy was discontinued for 25 days. The patient exhibited ambulation difficulty with shortness of breath and persistent irregular pulse, especially when rehabilitation therapy was reinitiated. These symptoms did not appear while the patient was outside of rehabilitation therapy. At the time of writing, she started to recover her declined ambulation with rehabilitation therapy, but was still dependent in toileting.

Immobility syndrome in elderly patients negative for coronavirus disease 2019 can be aggravated following the occurrence of a low-level cluster of coronavirus disease 2019 infections. Medical workers should, therefore, always consider this hidden risk and should plan an adequate program in the early period of rehabilitation therapy for the elderly patients. 

Case Report: A Rehabilitation Practice Report During ICU Management for a Patient With Multiple Disabilities Due to COVID-19 Pneumonia and COPD

Patients with severe coronavirus disease (COVID-19) and admitted to the intensive care unit (ICU) are at high risk of developing ICU-acquired weakness and disuse syndrome. Although their medical management may include prolonged deep sedation for pulmonary protection and ventilator management, we aim for early mobilization of these patients with COVID-19. We present the case of a 71-year-old man with chronic obstructive pulmonary disease (COPD) and COVID-19 pneumonia. Passive range of motion training and sitting on the edge of the bed were started in the ICU while the patient was under deep sedation. His activities of daily living eventually improved to where he could independently walk to the toilet without respiratory distress. Patients with severe COVID-19 who require mechanical ventilation are at risk of muscle weakness and exercise intolerance. These patients require rehabilitation therapy, beginning in the acute phase of illness, to recover their physical function. Although validation with a larger cohort is necessary, our results suggest that patients with COPD and COVID-19 pneumonia should undergo rehabilitation concurrently with status-driven changes in respiratory management.