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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 248-255

Inpatient and home-based rehabilitation regimen after COVID-19 illness


1 Department of Neurology, UP University of Medical Sciences, Etawah, Uttar Pradesh, India
2 Department of Physiotherapy, UP University of Medical Sciences, Etawah, Uttar Pradesh, India
3 Department of Orthopedics, UP University of Medical Sciences, Etawah, Uttar Pradesh, India
4 Department of Obstetrics and Gynecology, UP University of Medical Sciences, Etawah, Uttar Pradesh, India
5 Department of Neurosurgery, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India

Date of Submission20-Sep-2020
Date of Decision22-Oct-2020
Date of Acceptance19-Feb-2021
Date of Web Publication8-Apr-2021

Correspondence Address:
Neha Dubey
Department of Physiotherapy, Uttar Pradesh University of Medical Sciences, Saifai - 206 130, Etawah, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_134_20

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  Abstract 


The severe acute respiratory coronavirus-2 syndrome infection has spread worldwide and has an abrupt effect on human, economic, and health system. The data are collected from various relevant sources such as PubMed, Infection Prevention Control, World Health Organization novel coronavirus disease (COVID-19) situation update report, Australian and New Zealand Intensive Care Society guidelines, Society of Critical Care Medicine, World Confederation for Physical therapy guidelines, and from other Internet sources. It is observed that about 30% of COVID-19 patients with sepsis needed hospital rehabilitation, while 20% requires a home-based rehabilitation program. Based on the evidence, it is anticipated that severe and critical COVID-19 patients develop postintensive care syndrome, resulting in pulmonary disabilities, dyspnea on exertion, physical deconditioning, cognitive impairment, and mental health disturbances. Most of these symptoms may also occur in patients recovered from symptoms, or who were not admitted to intensive care unit, or in older adults with chronic health conditions, or who have been deconditioned due to mobility disability, social isolation, etc. Such patients need access to effective pulmonary therapy, functional rehabilitation, and stress management in the hospital- and home-based settings to regain their previous independence level. The evidence suggests that viruses could even survive in the oropharyngeal cavity and stool for up to 15 days after COVID-19 infection has been declared cured. The physiotherapist must take proper safety measures before managing patients at home; a virtual care therapy is therefore highly recommended. Due to the increasing demands of hospital beds, the patients may need to be discharged earlier than expected. Rehabilitation act as adjuvant therapy in preparing patients for discharges, reducing the experience of disability, and ensuring the quality of treatment among recovered/discharged COVID-19 patients in hospital- or home-based settings.

Keywords: COVID-19, hospital and home-based rehabilitation program, recovered or discharged, safety measures


How to cite this article:
Yadav R, Dubey N, Kumar S, Kanti V, Kumar R. Inpatient and home-based rehabilitation regimen after COVID-19 illness. CHRISMED J Health Res 2020;7:248-55

How to cite this URL:
Yadav R, Dubey N, Kumar S, Kanti V, Kumar R. Inpatient and home-based rehabilitation regimen after COVID-19 illness. CHRISMED J Health Res [serial online] 2020 [cited 2021 Apr 19];7:248-55. Available from: https://www.cjhr.org/text.asp?2020/7/4/248/313173




  Introduction Top


COVID-19 is a highly infectious disease caused by severe acute respiratory coronavirus-2 syndrome (SARS-CoV-2), which was first identified on the wholesale seafood market in Wuhan, Hubei, China, in December 2019. Globally, the virus has an abrupt effect on the human, economic and health systems, including the current rehabilitation practice. The total number of confirmed cases reported in India on October 19, 2020, is 7,597,063, 8,04,528 cases are still active, 1, 15, 197 have died due to the novel coronavirus, while 64,53,780 people have been cured or discharged or have been migrated. Globally, about 40,118,333 confirmed Cases along with 1,114,749 deaths were recorded.[1] The World Health Organization (WHO) and Physiotherapy Association have developed standards for patients suffering from COVID-19 infection.[2],[3] The recent WHO report providing scientific evidence on the transmission of the virus during aerosol-generating procedures and the likelihood of generating microscopic aerosols (<5 μm) by evaporation or by quiet breathing or speaking that generates exhaled aerosols.[4]

The infection causes a cytokine release causing high inflammation levels, resulting in pulmonary damage characterized by edema, prominent protein exudates, vascular swelling along with systemic injuries, and so many patients with novel coronavirus disease (nCOVID-19) needed acute intervention to recover from the symptoms associated with infections. Based on the evidence, the acute interventions for severe and critical COVID-19 patient includes mechanical ventilation, sedation and/or prolonged bed rest which are expected to result in a range of impairments including physical deconditioning, pulmonary disabilities, and cognitive and mental health impairments. These symptoms are collectively referred to as postintensive care syndrome. These syndromes are associated with poor long-term outcomes, especially in the patients who had acute respiratory distress syndrome, prolonged ventilation and sepsis[5],[6] so rehabilitation aims to improve patient's recovery and reduces the involvement of associated disabilities. The older people and severely infected patients of all ages may be most vulnerable to their impact. Most of these symptoms may also occur in patients recovering from severe COVID-19 who were not admitted to intensive care unit. Such patients need access to effective pulmonary therapy, functional rehabilitation, stress management, and counseling and self-management approaches for activities of daily living in the hospital- and home-based settings.[5],[6],[7],[8],[9],[10],[11],[12],[13] Graboswki DC suggests that 30% of COVID-19 patients with sepsis needed hospital-based rehabilitation while 20% requires home-based rehabilitation program.[14]

Post-acute care is beneficial for respiratory, mobility, and functional recovery together with practicing techniques to reduce stress and improves performance. The mental rehearsal techniques (MRTs) act as a cognitive rehearsal of a task by imagining the performance in mind to alleviate redundant tension and prepare the mind and body for action by using mental imagery procedure. Home-based rehabilitation, including virtual care therapy, can be appropriate for COVID-19 patients with previously identified abnormalities or who have been discharged from the hospital.[15],[16] Virtual care therapy promotes social distancing; helps medical centers in managing prolonged waiting times, risk of disease progression, and protect physical therapists from an unintentional spread of infection. With the high demand for hospital beds, patients may need to be discharged earlier than anticipated. This article attempts to assess the importance of rehabilitation in the management of inpatient and home-based rehabilitation regimen after COVID-19 illness.


  Methodology Top


The search for the relevant journal was carried by searching keywords Physiotherapy Rehabilitation in COVID-19 illness through the use of the PubMed, PubMed Central, WHO nCOVID-19 Situation Update Report, Invention Prevention Control, Australian and New Zealand Intensive Care Society Guidelines, Society of Critical Care Medicine, National Institute for Health and Care Guidelines, Ministry of Health Guidelines, World Confederation for Physical-therapy Guidelines, and from other Internet sources.


  Clinical Sign after COVID-19 Illness Top


Throughout the acute period, the COVID-19 patient exhibits different clinical expressions. (a) Mild case exhibits no dyspnea and no reduced oxygen concentration in the blood (SpO2). (b) Moderate symptoms are associated with dyspnea with 94% to 98% oxygen saturation and with radiological signs of pneumonia. (c) Severe conditions lead to dyspnea with (93%) oxygen saturation, respiratory rate (>30/min), a radiological progression of lesions and O2 supplementation with noninvasive ventilation is needed. (d) Mechanical ventilation is needed in critical patients.

In establishing a rehabilitation plan for COVID-19 patients, the concern must also be given on the significant comorbidities associated with nCOVID-19 such as (a) hypertension (55%), (b) coronary artery disease and stroke (32%), (c) Diabetes (31%), and the minor abnormalities like chronic obstructive pulmonary disease (7%), (e) immunodeficiency (1%), <1% central nervous system diseases.[17],[18] However, this information continues to expand. The data obtained from the numerous studies suggest that patients over 60 years of age with smoking history and comorbid health problems are the main contributors to intensive care unit and mortality risk due to nCOVID-19 infection.[19]

Herridge et al. demonstrated that patients admitted to intensive care unit with acute respiratory distress syndrome or those who stay for a more extended period in the hospital may develop symptoms such as respiratory muscle weakness, muscle wasting and weakness, loss of mobility, depression, and anxiety.[20],[21] Many studies have indicated long-term cognitive impairment after acute disease. Thus, it could have been theoretically possible that cognitive disability (attention, memory, vision-spatial disorders, etc.,) would occur and affect 70%-“100% of discharge patients, 46%-“80% after 1 year and 20% after 5 years.[15],[20],[22]

The virus remains in the patient's oropharyngeal cavity and stools for up to 15 days after being confirmed COVID-19 cured without fever, respiratory symptoms, and two consecutive negative swab samples of reverse transcription polymerase chain reaction. Since the SARS-CoV-2 virus can survive, the patient may still transmit diseases and probably infect other patients or health care worker in the rehabilitation unit. Hence, a patient is kept under close monitoring, and the therapist must also take complete protective pretreatment measures.[23]


  Discharge Criteria after COVID-19 Illness Top


The patient transferred from intensive care unit to inpatient unit or discharged at home must be assessed for mobility and functional disturbances, pulmonary disability, cognitive impairment, and mental health.[9],[17],[24] Although the current COVID-19 inpatient approach relies heavily on oxygen control, selected patients could be discharged if oxygen administration could be addressed safely, under well-designed and properly established regimes. Based on data from the Ministry of Health and Family Welfare, the revised discharge criteria for all COVID-19 confirmed patients are listed in [Table 1].[25]
Table 1: Revised discharge criteria for coronavirus disease-19 confirmed patients

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  Instructions for Physiotherapists Top


  1. The patient discharged from acute care must be strictly constrained to the allotted bed in the rehabilitation unit
  2. Ensure that the distance between patient's beds must be 2 m to prevent physical contact or transmission during the speech, eating, or performing exercises
  3. Emphasis must be given to physiotherapist expertise in the cardiorespiratory with proper knowledge of dealing patient in intensive care unit[26]
  4. There must be strict compliance of wearing complete personal protective equipment (PPE) kit by the therapist during the delivery of therapy to the patient to minimize the risk of transmission
  5. Ensure that therapist must be rehydrated prior wearing PPE especially in summers to reduce the risk of dehydration. As in India, the health-care workers due to long duty hours complained of excessive sweating, restricted movement with PPE. It is highly recommended to restrict duty to not more than 6 h and 14 days rotation plan for a therapist working in inpatient unit with frequent health check-ups[14],[27]
  6. There is a need of anti-fog safety glasses to prevent moisture over the goggles for smooth conduction of physiotherapy techniques
  7. The patient must be explained about the procedures and techniques before the application
  8. The physical therapist must provide one-on-one therapy to a patient and prohibit group therapies especially in unit/wards
  9. The focus must be given on the application of single equipment rather than in bulk, for example, use of theraband instead of weight cuffs
  10. The treatment equipment shared between patients must be disinfected and handle with care after every session (such as electrode, sponges, velcro straps, hot and cold packs, gel bottle, towels, manual dexterity training equipment, such as Goniometer, handheld dynamometer)
  11. To improve the functional mobility, the patient, along with one therapist, must be allowed to walk in the vacant areas of the hospital/or of home
  12. There must be a provision of a weekly training of donning and doffing techniques, rehabilitation, and weekly webinar with e-learning materials by experienced and qualified therapists due to repeated changing guideline by the WHO
  13. The therapist must also keep track of the evolving recovery needs for the patients.



  COVID-19: Rehabilitation and Postdischarge Care Top


Rehabilitation is more demanding for people recovering from COVID-19 or shifted from intensive care unit to inpatient unit/ward or at home. The discharge policy are earlier than expected due to a shortage of bed, so rehabilitation is beneficial for preparing patients for discharges, coordinating complex discharges, and ensuring that the patient does not deteriorate following/or after discharge and require readmission. Before performing these techniques, the patient status must be checked through various tests and procedures. [Table 2] demonstrates various assessment and examination done after COVID-19 disease.
Table 2: Assessment of coronavirus disease-19 patients

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Rehabilitation program depends on the symptomatic requirements of COVID-19 patients and may include: (1) respiratory rehabilitation, (2) functional rehabilitation, (3) stress management, (4) home-based rehabilitation program.

Respiratory rehabilitation

Lazzeri et al. suggested that in the early recovery phase, chest physiotherapy should not be applied, as it could lead to respiratory distress. Secretions can increase if the disease is associated with underlying causes such as bronchiectasis, secondary pneumonia, or aspiration.[30] Patients must be kept under close monitoring of their vitals and other symptoms such as dyspnea, decreased saturation (<95%), blood-pressure (<90/60 mmhg), heart-rate (>100 bpm), temperature (>37.2°C), and excessive fatigue before applying these techniques in unit or at home after discharge.[31],[32]

Management of breathlessness

The SARS-CoV-2 infection enters the type-II alveolar cells (AT2 cells) through angiotensin-converting enzyme-2 receptors, which are mainly distributed in the lung tissues, making the lung the primary target organ. About 50% of COVID-19 patients develop dyspnea 1 week after the disease starts, which in some patients can quickly lead to severe respiratory distress syndrome, metabolic acidosis, and even death.[33] The patient who recovered from COVID-19 or discharged from the hospital may also experience difficulty in breathing during physical exertion. According to the United Kingdom National Health Service Guideline, the patient room in unit/or at home must have proper air circulation. According to WHO Breathing exercises and Proper Bed Position are important rehabilitation components in managing breathlessness during physical activity, exacerbation of respiratory diseases after COVID-19 illness.[34] [Table 3] demonstrates various bed positions and breathing exercises that may be beneficial in patients who have recovered from COVID-19 disease or have been discharged from the hospital.
Table 3: Management of breathlessness after coronavirus disease-19 illness

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Secretion management

The instant gravity-assisted draining technique/or prone position is highly recommended in unit/or at home to drain secretions and improve ventilation after COVID-19 illness.[26],[35] The patient in a unit with sedatives and conscious problems must be kept on a tilting table with the head end elevated to (30°-“45°-“60°).

Impaired respiratory muscle performance and COVID-19

Recent article highlighted the correlation between respiratory muscle performance and COVID-19.[36] Patients with poor baseline health, such as those who are old or weak, smoked, chronic, or overweight, are more likely to have impaired respiratory muscle performance. These patients have the greatest risk of developing complications after COVID-19. Evidence from several countries suggests that physiotherapist combines respiratory rehabilitation with inspiratory muscle training (IMT) to treat patients with lung conditions in unit/or at home. Patient on ventilation causes rapid wasting and weakness in the inspiratory muscles, and IMT restores and bring back the strength.[37]

Airways clearance technique

  1. Positive expiratory pressure devices[26]
  2. Diaphragmatic training: In the supine position, about 1-“3 kg weight is kept on the patient's stomach, and then he/she is asked to breathe in and out
  3. Pursed lip breathing technique: The patient is asked to sit with back straight and then breath in through the nose for about 2 s, purse the lip and blow out the inhaled air very slowly for about 4-“6 s, and repeat it for 5-“6 times twice a day
  4. Active cycle breathing technique.[26]


The technique is done in three phases. In the first phase (breathing control), the patient is asked to sit relax and gently breath-in through the nose and out through the mouth to relax airways. In the second phase (chest expansion exercises), the patient is asked to breathe in deeply and then breathes out like a 'sigh' without forcing the air out. This can be accomplished by clapping or vibrating the chest, followed by another phase of breathing control. Repeat 3-“5 times. In phase three (forced expiratory techniques), the patient is asked to huff to move mucous up the airways until all the mucous have been huffed out.

Functional rehabilitation

Physical therapy plays a beneficial role in increasing strength and endurance among the deconditioned systems of the body. The patient transferred from intensive care to inpatient unit/ward or discharged at home needs to perform these exercises under the supervision of physical therapist either physically or virtually will help to improve performance and reduces complications that arises after COVID-19 illness.

  1. Bed mobility task: It promotes independence and allows for self-care activities. Due to physical inactivity and psychologically induced functional decline, it is a highly recommended bed mobility task for patient recovering from COVID-19 infection in unit/or at home
  2. Ankle pump: Due to physical deconditioning of the body after COVID-19 illness, an ankle pump exercise will assist to pool blood in the lower limb and also increase blood flow. Toya et al. stated that increased amount of blood flow velocity increased with increasing rest time, so ankle positions and exercise intervals must be taken into account for performing effective ankle pumping exercises[38] [Figure 1]a and [Figure 1]b
  3. Shoulder lift and chest stretch: These exercises strengthen the weak accessory muscles of respiration, increases the flexibility, range of motion, improve upper body posture, and allow for pain-free movement patterns
  4. Sit to stand exercise: Patient is asked to sit on a bed/chair with hip and knees flexed to 90°, clasp the hand and place it over the back of the head, place a pillow in between the knees, ask patient to stand while pressing the pillow, repeat for five times two sessions/day. This exercise will help to strengthen the legs, lower trunk, and core muscles. The same exercise pattern will be followed from standing to sitting [Figure 1]a and [Figure 1]b.
  5. Balancing exercises such as (a) stand on one foot, hold it for 5 s with eye closed, return and repeat for five times, (b) walk in a straight line. The patient deconditioned/or with diminish voluntary control due to extended stay in hospital will be benefitted by these exercises [Figure 1]a and [Figure 1]b.
Figure 1: Ankle pump. (a) Dorsiflexion, (b) Plantarflexion

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Figure 2: (a) Sitting with hip and knee flexed to 90°, Place pillow in between the knees, and clasp hand behind the head, (b) Stand while pressing the pillow between the knees

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Figure 3: (a) Standing on one foot, (b) Walk in a straight line

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Stress reduction technique

Covid-19 has caused severe distress around the globe. In addition to the physical symptoms in infected cases, COVID-19 has caused severe damage to mental health. Such disorders of mental health (depression, anxiety, etc.) affect people's thoughts, feelings, and behavior, which impact their ability to communicate and interact with others every day.

Evidence proposed that patients affected by stress, depression, if practice movement with mental rehearsal and meditation on the daily basis helps to share neural substrates that are potentially beneficial in reducing stress, and depression thereby increasing muscle strength and physical performance among patients.[39],[40],[41],[42] These finding suggests that there is a probability that COVD-19 patient in inpatient unit/ward or post discharged at home, if practice these techniques, will be benefitted from relieving stress and depression. More research needs to be carried out to validate this technique.

Mental rehearsal technique

MRT is a mindfulness-based cognitive therapy in which there is a cognitive rehearsal of a task by imagining the performance in mind to alleviate redundant tension and prepare the mind and body for action. The techniques include: (i) imagery in which a patient experiences a situation through multiple sensory approaches such as physical, visual, or auditory to validate appropriate responses. (ii) Observation of movement before rehearsal to acquire new creative skills, activity and stress reduction. (iii) Self-discussions with oneself to motivate the performance, thereby reducing stress and depression.

Mindfulness meditation

It is a mindfulness-based-stress reduction technique that involves sitting calmly, breathing deeply, and drawing the attention of the mind to the present moment without moving into past or future concerns.


  Home-Based Rehabilitation Program Top


According to the WHO recommendations, all patients with mild illness associated without underlying disorders like lung or cardiac problems, renal failure, or immunocompromised circumstance must be treated at home to avoid the risk of developing complications. Because of inadequate bed space, resources, and lack of inpatient care. Evidence suggests that home-based oxygen therapy by the use of transportable or portable oxygen concentrators (smaller in size and weight at flow rates of 4 L/min or less)is helpful for delivering safe care and reducing hospital burden in the current pandemic.[43],[44]

The physiotherapist must follow the correct steps prior handling patient at home[16] [Table 4]. The physical therapist must take proper precautionary measures such as wearing a complete PPE, keeping a bottle of sanitizer, Sterilize equipment bag which includes modalities, electrodes, coupling media, and exercise materials.
Table 4: Steps to follow prior managing patient at home

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The patient discharged from the hospital does not engage voluntarily in any exercise prescribed at home, resulting in deconditioning of their body system, so a properly designed virtual care therapy session is strongly recommended. This therapy promotes social distancing measure; helps medical centers in managing prolonged waiting times, risk of disease progression, and protect physical therapists from infection. The session must include counseling and guidance on self-management approaches such as activities of daily living, breathing exercises, chest expansion exercises, active limb exercises to improve performance, general fitness, and functional mobility after COVID-19 illness.[45],[46]


  Conclusion Top


Despite of well-established guidelines on COVID-19 disease, physiotherapy rehabilitation in inpatient and at home-based settings would be quite helpful in somehow managing breathlessness through positioning, clearing secretions, strengthening weak, and deconditioned muscles through various interventional techniques, reducing stress, incorporating self-management approaches for the activity of daily livings, and by regaining previous independence levels after COVID-19 illness. In the case of re-infection, where a pulmonary reserve is low due to superimposed infection, there is an increased load on the cardiopulmonary system. The rehabilitation program will somehow help in improving pulmonary reserves in patients. Home-based oxygen therapy is helpful in delivering carefree service while diminishing the burden of the hospital. The COVID recovery program must also include virtual care therapy for a discharged patient at home. The physical therapist must take the astringent barrier method regarding safety measures either before wearing PPE kit or during any contact with the patient either in the rehabilitation unit or at home as the virus may persist in the oropharyngeal cavity and stool for up to 15 days. Referring through many databases, we can conclude that rehabilitation would be beneficial in preparing patients for discharges, reducing the risk of readmission, optimizing patient recovery, reducing the experience of disability, and ensuring the quality of treatment among recovered/discharged COVID-19 patients in the hospital- and home-based settings.

Acknowledgment

The author would like thank the department of neurology and physiotherapy for providing all possible support for smooth conduction of this article. I would also like to acknowledge to my colleagues for their guidance and timely help throughout the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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