Post-Covid Rehabilitation

COVID 19 is the name given by the WHO on February 11 2020 for the disease caused by the novel coronavirus SARS –COV-2 (named because the virus is a genetic cousin of the corona virus which caused the SARS outbreak in 2002. It takes approximately 2-10 days for transmission. It spreads by droplet infection and remains viable for at least 24 hrs on hard surfaces and up to 8 hrs on soft surfaces.

The disease severity ranges from an

· Asymptomatic infection-80%

· Mild upper respiratory tract illness-80%

· Severe viral pneumonia with oxygen support- 15%

· Critical cases of respiratory failures requiring ventilation and life support- 5%

· Death -5%

Complications

· Acute respiratory distress syndrome

· Sepsis and septic shock

· Multiple organ failure including acute kidney injury and cardiac injury

· Stroke

· Pulmonary embolism and thrombosis

· Covid toes in children below 12- 18 yrs.

Diagnostic Tests

·Nasopharyngeal or throat swabs using a reverse transcription polymerase chain reaction

· Antigen   test

· Antibody test

Ct scan is better diagnostic tool than x-rays
CO-RADS CLASSIFICATION

 

CO-RADS

LEVEL OF SUSPICION 

CT FINDINGS

1

No

Normal or non-infectious abnormalities

2

Low

Consistent with other than covid-19

3

Intermediate

Unclear weather covid-19 is present

4

High

Abnormalities suspicious for covid

5

Very high

Abnormalities typical with covid

 

CT severity score
Infection Criteria (single lobe)

 

5% Infected

Score 1

5 – 25 % Infected  

Score 2

25- 50 % Infected

Score 3

50 – 75 % Infected

Score 4

>75 % Infected

Score 5

 

Score calculation is based on each lobe involvement. Each lobe has maximum score 5 and so 5 lobes has maximum score 25.

 

Role of Post Covid Physiotherapy- WHO recommends

·  Minimal staff

·  Proper PPE (IPC measures)

·  Closed suctioning

·  Avoid aerosol generating procedures

· Cough etiquettes  for both staff and patient

· Early mobilization even in acute critical cases

 

Outcome Measures

·  Strength  – MMT

· Endurance/submaximal Exercise testing – sit to stand test/ 6 minute/ 2 minute walk test

·  Balance – Berg Balance scale

· Cognitive – Galvestian Orientation Test (GOAT)

Assessment (as per the requirement and stage)

·   Dyspnea – Modified Borg scale

·   Heart rate

·   Oxygen saturation(spo2)

·   Blood pressure

·   Pulmonary function(by spirometry)

· Quality of life (QOL) – Nottingham Health Profile Survey

 

 

Physiotherapy Treatment for patients recovering from Covid

Physiotherapy management differs depending on the underlying condition

· Severely acute ventilated patients

· Patients on HFNO(high  flow nasal oxygen)

· Moderate to mild cases

· Asymptomatic cases

· Home care

· Post recovery

 

Severely acute patients

The quotation declared by WHO states that acutely unwell confirmed or suspected covid 19 patients should not be routinely referred to physiotherapy. There are currently no reports that suggest covid-19 patients have high secretionloads requiring intensive respiratory physiotherapy/ airway clearance.

In Post Covid Rehabilitation – intervention likely to be limited benefit in the acute stages. Physiotherapists will have a role in the rehabilitation of covid 19 patients who have not returned to their functional baseline once they are no longer actually unwell.

                 As per the research related to ARDS, prone ventilation is suggested to be an effective strategy in mechanically ventilated patients. Adult Patients with covid 19 and prone Ventilation for 12- 16 hrs per day is recommended and to be performed safely.

                Bronchial hygiene to be given as per the requirement of the patient as an individual based, depending on the accumulation of secretions

EARLY Mobilisation in Post Covid Rehabilitation

Criteria for early mobilization

· Conscious- able to obey commands

· CVS- not on inotropic support, no arrhythmia/ ischemia in past 24 hrs.

· Respiration;fio2<50%, PEEP<8

· Muscle power : UL&LL>3 ( individual dependent)

· Blood/biochemistry – within normal range

Steps to be followed

1 Propped up

2 Edge of the bed sitting

3 Leg dangling, ankle pumps, upper limb movements

4 Bedside chair sitting

5 Standing/ wheelchair

6 Sit to stand

7 Spot marching

8 Gradually mobilize with frequent intervals

Severe recovering cases

· Early mobilization

· Initiation of breathing exercises

· Diaphragm facilitation(scooping, lateral stretch, upper chest inhibition)

· Breathing facilitation and exercises

· Prone positioning as per the need

· Ankle pumps for good venous return

· Limb mobility exercises

· Limb strength and endurance

· Cognitive functions

Pulmonary rehabilitation includes

·  Respiratory component

· Neuromuscular component

· Cognitive component

Criteria for “mild” disease (for age>12) to manage at home

· Spo2>95%

· Respiratory rate<25

· Heart rate<120

· Temp 36-39 degrees

· Mental state normal

Full recovery can take several weeks, especially in severe cases.

Preferable breathing exercises based on diseases severity

·   Diaphragmatic breathing

· Pursed lip breathing

· Bronchial hygiene/lung re expansion techniques

· Huffing& coughing(rare)

· Prone breathing exercises

·  Active cycle of breathing

· Thoracic expansion exorcises

· Incentive Spirometry

· Ballon bladder exercises

· Breath stacking technique

Neuromuscular training

Goals

· Reduce edema in the extremities

· Optimizing and maintaining ROM

· Optimizing and maintaining muscle strength,  endurance

· Improving the diaphragm strength

· Preventing muscular atrophy

· Normalizing and developing muscle tone

· Optimizing effort tolerance

Treatment

·  Bed mobility exercises

· Mobilization out of bed

· Respiratory and postural muscle training

·  Sitting balance retraining

· Walking

· Use of tilt table

· Upper limb or lower limb ergometry

· Use of NMES to prevent atrophy

Cognitive Component

·   Psychological support

· Mental relaxation

· Meditation

· Nutritional counseling

· Good sleep

Speech therapy for dysphonia and dysphagia

· Frequency – twice a day

· Duration – patient dependent

· Repetitions – start with low reps

· Mode – start with interval training

Check out these links for relevant information: Cardio
vascular pulmonary rehabilitation.

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