IMPORTANCE OF REHABILITATION IN COVID-19 PANDEMIC

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Today due to corona pandemic, the whole world is under lockdown. This has lead to altered daily routine of all people. This changed life routine has caused impact in various domains of performance areas (BADLs and IADLs), performance components and performance context.  

People who are affected with Corona virus (COVID patients) are facing physical problems (like breathlessness, cough, fever, aches and pains), psychological problems (like stress of being Corona positive, chances of survival, guilt of getting corona virus, physical isolation, loneliness, family concerns), difficulties in performing activities of daily living due to dyspnea caused by decreased lung functioning and decreased oxygen saturation in blood.  

Non-COVID patients (patients having other diagnosis) like stroke, spinal cord injury, fractures, burns, myocardial infarction etc who were on  longterm rehabilitation program had to temporarily reduce their therapy sessions and thus compromise health and functional recovery outcomes.

Non-infected people are bounded to stay at home and do work from home. Children are mostly engaged in watching television, mobile phones and playing games for longer duration. This changing behaviour is leading to sedentary living with lack of exercises or physical activities, irregular sleep patterns and overeating. On the other hand, homemakers are all the time engaged in completion of house chores thus their chances of physical pain might increase. Some people who were working on daily wages have lost their jobs and are facing economical crisis. Similarly, government servants like police officers, healthworkers, political leaders and other officers and employees,  home-delivery services etc are also under continuous threat of getting corona virus due to their job demands and extended duty timings.

Let us first put some light on what is corona virus and its pathology.

WHO definition : Corona virus (CoV) are a large family of viruses that cause illness ranging from common cold to more severe diseases such as Middle East Respiratory syndrome (MERS-CoV) and Severe Acute Respiratory syndrome (SARS-CoV). COVID-19 virus is primarily transmitted between people through respiratory droplets or contact route. 

A novel corona virus (nCoV) is a new a strain that has not been previously identified in humans. 

• CoV has reported to cause damage to respiratory system mainly lungs (alveolar gases exchange affected). Patients with COVID 19 have increased plasma concentration of inflammatory cytokines, such as tumour necrosis factors alpha, interleukins (IL) 2, 7 and 10.
• COVID-19 patients have decreased lymphocytes in peripheral blood.
• In autopsy and biopsy samples of COVID-19 patients it showed bilateral diffuse alveolar damage including edema, proteinaceous excudate, multinucleated giant cells and focal reactive hyerplasia of pneumocytes with patchy inflammatory cellular inflitration. Also, focal lymphocytes, plasma cells and monocytes infiltrates pulmonary interstitium. 

All these changes impedes alveolar gases exchange and decreased oxygen level in blood. This leads to decreased endurance, generalized weakness in body and affected occupational performance in daily activities.

Looking at the current scenario of the world, COVID-19 has caused negative impact on everybody's life. There is an increased need to rehabilitate both COVID and non-COVID patients and common people. Interdisciplinary team approach is needed for complete and good recovery of patients. Since, COVID-19 is a novel corona virus and its treatment protocol is under research, therefore it is important to note that the current therapy protocol is based on the knowledge figured from various underlying health conditions. Rehabilitation is necessary after every critical hospitalized conditions so the patient can again become functionally independent in daily activities, maintain his/ her quality of life and reduce chances of severe disability. Physiotherapist and Occupational therapist plays an important role in recovery process.

• COVID patients who are hospitalized needs proper acute, subacute and longterm long program which includes pulmonary management, physical exercises (range of motion and strengthening exercises), psychological support, exercises and motivation to promote independence and ADL retraining, cognitive retraining, teaching energy conservation techniques, cognitive behavioral training, aerobic exercises and adaptive devices or home modifications.
• Non-COVID patients can be treated with help of computer technology using Telehealth services (refers to the use of telecommunications and virtual technology to deliver health care, including rehabilitation, to patients), for discharged patients, at homes. Before hospital discharge, a comprehensive home programme must be explained.  Periodic checking  of patients recovery  must be done through phone calls or video calls followed by demonstration and educating with new exercises if required.
• Non-infected people should be educated to live a healthy lifestyle, follow government rules and safety measures against corona virus. 

Role of rehabilitation  can be divided into two stages of prevention related to COVID-19 : 

1) PRIMARY PREVENTION:  mainly for non-infected people i.e. COVID-19 negative people. It aims to avoid the development of disease in healthy individuals. Intervention approach is based on health promotion and awareness. Therapist can take active participation to promote health and spread awareness against COVID-19 by :

For Non-infected people

a) Educational approach: To educate people and their family about affects of COVID-19  on body and its precautions. Information about safety precautions includes  

• Wearing face mask outdoors. Avoid talking face to face with people for longer duration. Maintain safe distance, wear mask, limit unnecessary conversation.
• washing of hands at regular intervals for minimum 20 seconds. Using hand sanitizers when required.
• After touching any commonly used machine or object with hands then avoid touching your face directly without cleaning your hands.
• Implementing rules and regulations of  government like following social distancing rule at every place you visit ( maintain safe distance of about 5 to 6 feet)
• Avoid going outdoor if not necessary. Avoid participating in social gatherings. People who are at high risk are geriatric population, pregnant women, immunocompromised patients, infants and children.
• Wash fruits and vegetables properly with water before consuming. This is because the Coronavirus has the ability to stay on the surface for upto 48 to 72 hours. If the product is used after three days, the presence of virus or its residual is unlikely. As far as groceries are concerned, they are safe if they are in a sealed container.  
• Adopt healthy eating habits i.e. consuming food that will improve immunity and avoid consumption of foods with high calories or saturated fats. 

b) Role of Physiotherapist, Occupational therapist, and other educated personnel : Approaching government officer of your locality or region to grant permission to therapists for taking a small group campaigns related to COVID-19 precautions by distributing pamphlets about home exercises programme, foods to consume to boost immunity, importance of social distancing etc. Preferably pamphlets should be in local languages and with pictures for easy understanding. People of India should take responsibility to take care of themselves and their family.

c) Taking initiative and approaching radio stations or news channels office and taking their permission to deliver a talk on safety measures, precautions and healthy lifestyle to prevent corona infection. Making use of social media platforms like facebook, instagram, youtube to educate people about COVID-19 and treatment process. 

d) 30 to 45 minutes of home exercises programme to be performed for atleast 5 days per week. It includes aerobic exercises, stretching exercises, deep breathing exercises, yoga etc. Appropriate exercise programme will improve your lung capacity, oxygen saturation in blood, improve immunity, endurance and muscle power. This will decrease the chances of gaining weight due to sedentary living. Contact Physiotherapist or Occupational therapist for exercises programme that should be followed at home with respect to age of the people. 

• How exercises helps to built immunity? : Light exercises promote the flow of lymph, immune cells and antibodies through body. Flow of lymphatic fluid depends on the body motion, muscle contraction and manual manipulation such as massage. Exercises strengthen the lungs to get rid of airborne viruses and bacteria that are associated with respiratory tract infection and also improves blood Oxygen saturation. Moderate to vigorous aerobic exercises of less than 60 minutes duration helps to enhance immunosurveillance. Regular bouts of appropriate exercise training has an overall effect of reduced systemic inflammation due to improved control of inflammatory signalling pathways, reduced IL-6, IL-8, tumor necrosis factor alpha and other inflammatory biomarkers in adult with higher levels of physical activity and fitness.

Image is taken from Pexels- free photos

Fig: Perform home exercises ( Image downloaded from pngtree website)

e) For people, especially those who are doing work from home, might have complaints of neck pain or low back pain because of sitting in bad posture while working on computers  or  laptops for longer duration. Proper ergonomic postures should be followed while doing any activities. We have learned about it in last articles titled "Lockdown and Low Back Pain".

https://otpthealthcarerehab.blogspot.com/2020/06/lockdown-and-low-back-pain.html

f) Stress management: In stressed conditions, the ability to fight infection is reduced. Stress leads to activation of fight or flight response. It triggers the release of  catecholamines and cortisol (stress hormone). Longterm stress can negatively affect immunity by lowering the number of lymphocytes present in the blood. Therefore, it is necessary to relax the mind in stressed conditions. It can be done by teaching deep breathing exercises, meditation, Cognitive Behaviour therapy, laughter therapy, exercises, guided imagery, communicating and sharing thoughts with your loved ones, diverting your mind by doing some other meaningful activity.

Fig : Stress management (Image is downloaded from shutterstock)

     (Image is taken from Pexels-free photos)

2) SECONDARY PREVENTION:  mainly for COVID and non-COVID patients. It aims to reduce the impact of disease that has already occurred by early identification and treatment. Intervention approach is based on remediation, adaptation, environmental modification and disability prevention approach.  

For COVID patients :

Physiotherapy has a great role in management of patients admitted in ICU, mainly cardiorespiratory physiotherapy plays vital role in management of acute and chronic respiratory conditions which improves their quality of life. Majority of Covid-19 patients have dry cough and there is no report of heavy secretion loads in these patients that may require airway clearance. In need for physical rehabilitation in patients with Covid-19, physiotherapy has major role when they present with symptoms of  breathlessness, decreased lung capacity and productive cough (if present).

Early mobilization is a key for ICU patients with acute or chronic illness which reduces the mortality and morbidity. Physiotherapeutic manoeuvres include body positioning to improve ventilation perfusion ratio and oxygenation in alveoli. Airway clearance technique to clear secretion from airways and alveoli. Early mobilization to such patient decreases ill effects of deconditioning and prevents critical care illness and improves quality of life.

Management goals:

• To gain full lung expansion
• To clear secretions from lung fields
• To exercise tolerance and fitness which improves quality of life

Treatment techniques:

Acute stage: (Hospitalized)

1) Body positioning :It can help in improving oxygen saturation, delay or reduce need of mechanical ventilation and recover  from respiratory illness in COVID-19. 

• Prone position, side-lying position with pillow under chest, gravity assisted position in non-comorbid patients for around 20-30 minutes in rotation etc.  Prone positioning will improve gas exchange by improving ventral-dorsal transpulmonary pressure difference, imrpoving lung perfusion and reducing dorsal lung collapse. For patients in which prone position is not possible semi prone position is given with use of pillows to improve ventilation.

Fig: Effectiveness of Prone ventilation

• Forward leaning position called dyspnea (breathlessness) relieving position should be taught to the patients with mild to moderate symptoms in sitting or standing position, This position will facilitate breathing and reduces work of accessory breathing muscles.

2) Breathing exercises :

This technique can be used by both patients with COVID-19 or without COVID-19. These are very helpful to improve full lung expansion if done in correct manner. It helps to improve oxygen saturation by reducing the work of breathing. Deep breathing exercises with diaphragm activation minimize the lung collapse. It corrects and improves the pattern and rate of breathing. The oxygen saturation (SpO2) level should be monitored in COVID-19 patients during breathing exercises.

• Diaphragmatic and Pursed lip breathing is mainly use for dyspnea and it is helpful in  preventing bronchospasm and provide relaxation. Breathing exercises should be done slowly and avoid taking a pause at the end of inspiration. Avoid doing forceful and rapid breathing techniques because this will make the patient more fatigue and more energy is utilised.
• Segmental breathing exercise is given to expand different lobes of lungs, therefore, it is called as localized breathing. It reduces the paradoxical (inappropriate) breathing pattern.

Fig: Pursed lip breathing and Diaphragmatic breathing (Image downloaded from Shutterstock images)

3) Coughing and huffing :

Teaching coughing and huffing techniques to the patients with productive cough is very useful but in COVID-19 cases these patients have dry cough so these techniques are not that beneficial. Also huffing and coughing produces aerosols which can transmit the infection further so these can be use with all safety precautions and when it’s required.

4) Nebulizers :

These are beneficial to patients with mild and moderate symptoms to reduce further lung complications.

5) Early mobilization :

Early mobilization with low intensity exercises can be given to patients with Covid-19 who are hemodynamically stable to improve their quality of life. It is important  because patients who were on ventilatory support, for many days, can lead to muscle wasting due to immobilization and weakness. 

• Start with light activities with gradually increasing to mild and moderate activities with proper monitoring of vitals (pulse rate, respiratory rate, oxygen saturation).
• Monitoring of vitals is very essential during therapy sessions. Observe for the signs of breathlessness, heavy breathing, palpitations, sweating etc. 
• Do initial evaluation of patients physical capacity using modified MRC dyspnea Scale or Borg scale for perceived exertion, Functional Independence Measure scale (FIM) and oxygen saturation levels (using pulse oximeter). Recommendations of daily work, ADL and leisure activities should be given based on patient's MET levels and with respect to patient's current body capacity. Avoid over exerting the patient beyond his physical capacity and body demands.

6) Use of respiratory inspirometer, blowing of balloons to increase the respiratory capacity and strengthen respiratory muscles. Breathing control exercises can be enhanced.

7) Stress Management techniques as mentioned above for non-infected people. Give them assurance that they will recover soon and the treatment for for COVID-19 is available. Support from the society is needed for COVID patients in acute and post discharge stages. Blaming eachother for spreading of Corona virus is not the solution.  Cognitive Behaviour therapy is needed which teaches to think positively and in correct ways should be learned and practised in their

Subacute and Chronic stage : Comprehensive discharge plan

• Continue with the respiratory management as mentioned in acute stage.
• Adopting Energy conservation techniques during performance of daily living activities. It includes:

1) Plan your activities for the day.

2) Not to overburden yourself with activities one after another. Pace yourself.

3) Taking of rest breaks during and between activities. This will give your body chance to recover.

4) Performing breathing exercises after every half an hour.

5) Avoid movements that involves bending, reaching and twisting. Avoid bending as it restricts your diaphragm, making it more difficult to breathe. Bring feet up to you or use any recommended adaptive equipment such as a reacher/grabber or a sock aid for dressing.

6) Ask for assistance if required and if help is available to you.

7) Whenever possible perform the task in sitting position.

8) Organize frequently used items at easy reach.

• Recovery from COVID-19 (moderate to severe patients) will be slow and the ability to return to everyday task will be gradual. Daily conditioning exercises and walking program should be gradually increased. Start with bed level and seated exercise program 2 to 3 times a day then gradually progress to standing exercises and later combined upper limb and lower limb exercises in chronic stage. Take frequent rest pause during and between exercises. Use the rate of perceived exertion (RPE) scale as a guidance of how hard patient is working.

To know more about importance of 'Energy Conservation Techniques for daily living'... Click on the below link ⬇️

https://otpthealthcarerehab.blogspot.com/2020/08/importance-of-energy-conservation.html

For Non-COVID patients : 

Due to lockdown these patients exercise programme is hampered. They are not able to visit therapy center nor the therapist is able to provide home-based rehabilitation. So, in order to meet these needs rehab professionals have to learn and adopt new strategies by keeping COVID-19 in our mindset. Major changes will be occurring in performance context/environment of the therapy. Changes should be made in the therapy centers so that the patient's therapy sessions is continued as well as chances of corona infection is also minimum or negligible. Following modifications includes:

• Therapist should make and paste charts related to the rules and regulations of COVID-19 that will be followed in rehabilitation centers. Instructions should be easy to understand with pictures and should be in local language as well as in english.

• Daily checking the temperature, pulse rate, oxygen saturation (using pulse oximeter) of patients before entering the therapy center. Washing of hands and forearm (upto the elbow level) before and after the therapy session.

• Sitting arrangements in the reception or waiting area should be at adequate distance of about 4 to 5 feets.

• Avoid crowding of the rehabilitation center. The number of patients in the center should be decided with respect to the working area of the center such that safe distance of 5 to 6 feet is maintained between patients. For children, preferably one to one therapy session should be arranged. Rehabilitation center should be well ventilated and spaced.

• Safe distance should also be maintained between all the therapy equipments and machines by changing their arrangements if possible. If not possible then limit the patients per therapy sessions to maintain safe distance. No two patients should be exercising in close vicinity of less than 6 feet distance.

• Therapist should be wearing proper face masks, face shield, hand gloves and personal protective equipments (PPE) during assessment and manual handling of patients for teaching new exercises.

• Patients should wear face masks and hand gloves during therapy sessions. For young patients, moderate to high intensity exercises should be avoided with face masks. For geriatric patients, frequent rest pause should be given to the patient during therapy sessions because exercising with face mask could reduce the ability to breathe comfortably. Since the body is not familiar to limited ventilation, therefore the heart and lungs tend to work harder than usual, resulting in increased risks of life-threatening conditions e.g. sudden cardiac death or heart attack. All the vital parameters should be monitored. 

• Foot operated water containers with disposable glasses should be used at rehabilitation centers. Preferably patients should be told to carry their own water bottle for drinking during rest time.

• Dustbins for proper disposal of used masks, gloves and PPE should be made. Regular sanitization of frequently used objects should be done.

• For recovering patients, the therapy sessions can be done via video calls or telerehabilitation. Therapist should make charts of various exercises techniques with pictures for easy understanding of patients. These charts can be e-mailed or sent to their whatsapp number.  

"Current WHO recommendations emphasize the importance of rational and appropriate use of all PPE, not only masks, which requires correct and rigorous behavior from health care workers, particularly in doffing procedures and hand hygiene practices. WHO also recommends staff training on these recommendations, as well as the adequate procurement and availability of the necessary PPE and other supplies and facilities." 

"At the end, in COVID-19 pandemic conditions the goal of rehabilitation is to continue making patients functionally independent in activities of daily living and improve their quality of life. Along with this safety of the healthcare worker is also essential."

Thankyou for reading!!!

( Dr. Pallavi Khadse-Kolhe, Dr. Sheetal Tatar-Dhande, Dr. Ashwini Sangar)

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