IAP National Guidelines For Physiotherapist in managing Post COVID 19 Patients

“The Indian Association of Physiotherapists National Guidelines for Physiotherapy Professionals in managing Post COVID 19 Patients during Recovery phase”
Dr Anjali R Bhise, Principal, Government Physiotherapy college, Government Spine Institute, Civil hospital, Ahmedabad, Gujarat
Dr K M Annamalai, chief Physiotherapist, Apollo hospitals International limited, Ahmedabad, Gujarat
Dr G Arun Maiya, Professor and Dean, Physiotherapy, MCHP, MAHE Deemed University, Manipal
Dr Mariya Prakash Jiandani, Assoc Professor, Physiotherapy School & Center, Seth GSMC & KEMH, Mumbai
Dr Vishwa Prakash Gupta, Chief Physiotherapist, Head-CTVS Physiotherapy Unit, Addl. Charge- CIMR, AIIMS, New DelhiProf. Narasimman Swaminathan, Professor in Physiotherapy, Vice Principal, Faculty of  Allied Health Sciences, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu
Dr Nehal Shah, Principal In-charge, SBB College of Physiotherapy, Ahmedabad, Gujarat
Dr Kanchan Anand, HOD Physiotherapy, Fortis Escorts Heart Inst, New Delhi
Dr Prem V, Associate Professor and HOD, Physiotherapy, MCHP, MAHE Deemed University, Manipal hospital, Bangalore
Dr Priyanka Rishi, Associate Professor, Head of Laboratories, Department of Physiotherapy, Lovely Faculty of Allied Medical sciences, Lovely Professional University, Punjab
Dr Sanjiv K Jha, Director CCDR, Principal RD Gargi, Madhya Pradesh
Dr RuchiVarshney, Director Ruchi Advanced Physiotherapy and Wellness, New Delhi
Dr Umanjali Damke, Principal and Professor, Physiotherapy S & C, Government Medical College and Hospital, Nagpur

Preamble

Since more than a year now entire world is witnessing the catastrophe of the COVID-19 pandemic. Currently, several countries around the world are in different stages of novelcorona virus infection, with many nations stepping into the post-COVID phase. As per WHO (World Health Organization), about 10% to 15% of COVID cases develop the ailment, and,about 5% of patients happen to fall critically ill. Usually, it takes two to six weeks for most of the corona virus infected individuals to recover from the infection.

COVID 19 has proved to be a multisystem disorder with a varied spectrum of presentation and lingering symptoms post recovery. The aftermath of COVID 19 in large proportion ofsurvivors is with debilitating symptoms of fatigue, muscle pain, lack of sleep, memory loss along with persistent respiratory symptoms. These may last for weeks or even months. Someindividuals might even be at risk of long-term impairment and need of long term oxygen therapy. The extent of impairment in the post-COVID phase is not yet known clearly, it isevident that many patients will need physiotherapeutic intervention for a longer period. Physiotherapist have been the frontline workers since the outbreak of the pandemic COVID19and have contributed in acute care therapy and are constantly thriving to help patients to improve their lung functions, ability to ventilate and oxygenate better and reduce the external demand of supplemental oxygen.

Knowing the impact post covid and persistence of symptoms there is a need to address these with apt Physiotherapeutic intervention measures. Considering the expected high burden of respiratory, physical and psychological impairment following COVID 19 infection, a huge number of patients should be referred early to a physiotherapeutic intervention program. Post COVID Physiotherapeutic intervention – Published Case reports and research from the other countries have highlighted the importance of Physiotherapeutic intervention in minimizing the disability and restoring normal functioning in the patient. Physiotherapy plays a crucial role in the recovery of Post Covid patients through the use of individualized tailored programs based on system involvement, support and patient education and thus improve their physical, functional and psychosocial abilities.

The Indian Association of Physiotherapist hereby proposes to update and adapt the national consensus recommendations of physiotherapy management in post -COVID 19 (JAPI Dec  2020) based on further gathered experience, consensus and literature and issue Guidelines for Physiotherapy in Post COVID 19 stage and thereby improving functional outcomes. A sustained program is the key to gain full function post covid especially those who had prolonged hospital and ICU stay

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Objectives

The objective of this Guideline is to provide recommendations for the physiotherapy assessment and management in post Covid 19 patients in the recovery phase. Physiotherapy aims to optimize recovery in commonly seen dysfunctions as below and any other which would interfere with quality of life.

A) Cardiovascular &Respiratory system dysfunctions:
1. Improve Respiratory muscle functions
2. Relieve dyspnea/breathlessness which is persisting for a longer duration post COVID
3. Improve Exercise Tolerance and aerobic capacity of the patients

B) Musculoskeletal System dysfunctions:
1. Improve muscle strength and endurance which are put on stake due to long term hospital and ICU stay
2. Pain and Fatigue Management
3. Management of musculoskeletal pains and weakness which are a sequela to the COVID infection

C) Neurocognitive Dysfunctions
1. Provide neurorehabilitation pathway to patients affected with neurological sequelae post covid 19
2. Improve Cognition, memory and sleep

D) Metabolic Dysfunctions
1) Many patients are known to develop glucose intolerance. Exercise plays an important role in glycemic control
2) Considerations for another organ involvement such as hepatic and renal

E) Overall Enhance health-related quality of life and return to normalcy

Scope:

This document provides information to physiotherapists who play a vital role in physiotherapeutic intervention of a patient with post COVID infection towards the path ofnormal functional recovery. It includes recommendation for

1.Pre-Physiotherapy Screening and assessment for physiotherapy intervention (including Red Flags)
2.Physiotherapeutic interventions based on system involvement
3.Special considerations
4.Safety and personal protection policy
5.Integration of adjunct therapies such as Yoga

Setting and Timing:Physiotherapy individualized tailor-made protocols are recommended for patients if they face residual respiratory, musculoskeletal and neuromuscular problems post COVID and areotherwise permitted to undergo such a protocol.

They can be carried out under following settings:

1.In-patient:-Indoor patients who have stabilized and are transferred in step down units while preparing for discharge
2.Home based / Community based:- Patients under isolation at home or quarantine center or in community halls.
3.Centre based :-Institute based physiotherapeutic intervention
4.Physiotherapeutic Intervention through Telemedicine - Using online platforms via video or telephonic consultation for the purpose of assessment and prescription ofphysiotherapy interventions.

• An initial consultation and shared decision-making process is advisable to discuss and agree with the person whether it should be by video, phone or in person. Take intoaccount whether they may have symptoms that need investigating in person or require  urgent referral to an appropriate service.
• A screening questionnaire should be considered to be used in conjunction with clinical assessment as a part of the initial consultation to help document all of the person'ssymptoms
• Support access to assessment and care for people with new or ongoing symptoms after acute COVID-19, particularly for those in underserved or vulnerable groups who mayhave difficulty accessing services.
• Patients with less symptoms can be treated through the use of tele-physiotherapy, educational videos, remote consultations through sound systems, self-management booklets, exercise videos
• During all such interventions except those on remote basis, both Physiotherapist and patient has to ensure all Covid precautions and hygiene
• Continuous monitoring of the vitals during the regime is mandatory

Core viewers:

Post Covid Physiotherapeutic intervention can be performed by any qualified Physiotherapist working in any set up. These patients can have plethora of problems ranging from fatigue and musculoskeletal pain to respiratory or neurological impairment. Physiotherapist shall be aware all such impairments and demonstrate competence to handle patients with a wide range of age and complexities in all settings. The physiotherapy team should design a tailor-made physiotherapy plan of care based on individual problems of each patient.

Commonly used terms during COVID 19 recoveryTo effectively treat and manage Post COVID condition it needs to be defined and distinguished from other conditions. A set of definitions has been used to distinguish 3 phasesfollowing infection consistent with COVID-19, and to define the term 'long COVID'. These phases are defined below.

Acute COVID-19

• Signs and symptoms of COVID-19 for up to 4 weeks.

Ongoing symptomatic COVID-19

• Signs and symptoms of COVID-19 from 4 weeks up to 12 weeks.

Post-COVID-19 syndrome

• Signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis.
  It usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. Post-COVID-19syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed.

Long COVID

• In addition to the clinical case definitions, the term 'long COVID' is commonly used to describe signs and symptoms that continue or develop after acute COVID-19. Itincludes both ongoing symptomatic COVID-19 (from 4 to 12 weeks) and postCOVID-19 syndrome (12 weeks or more)

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Section A: Placement of Physiotherapist

It is worthwhile to appoint dedicated team of physiotherapists in post Covid physiotherapeutic intervention set up

A1. It is recommended that qualified physiotherapists with required skills in providing Physiotherapy management pertaining to all impairments in the patient should be appointed

A2. Necessary training should be provided for the physiotherapists deployed in such Post COVID physiotherapeutic intervention by the specialist physiotherapists if required.

A3. Therapist placed in COVID care facilities should be trained in
1.Evaluation and assessment.
2.Identification of red flags.
3.Physiotherapeutic intervention through Telemedicine technology as required.
4.Safety Precautions and steps of hand washing technique, and disposal of biomedical waste as per institutional policy.

A4. It is highly recommended that therapist posted in post COVID care should be vaccinated as per Government of India’s guidelines.

Section –B: Physiotherapy Clinical Decision making

1.Physiotherapy decision making depends largely on manifestations of the patients, the associated movement dysfunction and physical therapy diagnosis. Patients with a limitation in physical /functional capacity and/or physical activity, impaired quality of life in various domains and those with known system dysfunctions are eligible for physiotherapy.

2.Physiotherapist should be able to assess the patient for impairments, activities and participation and develop a treatment plan focusing on maximal functional abilities with minimal energy consumption.

3.Decision making would be based on severity of symptoms and systems involvement.

4.Asymptomatic patients without any primary system involvement and in home quarantine with normal basic investigations would need to be evaluated for deconditioning effect and fitness due to restricted activity at home. Physiotherapist should formulate an exercise program to maintain activity and fitness at home.

5.Asymptomatic patients but having any other primary involvement of cardiorespiratory, neuromusculoskeletal or metabolic impairment should be evaluated as per system evaluation and identification to deliver physiotherapy care.

6.Symptomatic patients should be assessed based on symptoms experienced, origin of  source of symptoms, relevant assessment and investigation, contextual factors,pharmacotherapeutic interactions to reach physical therapy diagnosis and provide and execute plan of physiotherapy care.

The following residual effects can be experienced post covid 19.

1)Respiratory System.
a) Dyspnea/breathlessness (due to post-covid changes/fibrosis of the lung or pulmonary thromboembolism).
b) Oxygen support on activity or long-term oxygen therapy (due to persistent V/Q mismatch).
c) Difficulty in airway clearance (due to respiratory muscle weakness and/or atelectasis and/or hyper secretory phase due to long standing/associated lung infection).

2) Cardiovascular System
a) Palpitation’, chest pain, excessive fatigue in view of Myocarditis or Cardiomyopathy or Pulmonary thromboembolism
b) Poor exercise tolerance

3) Nervous System
a) Movement dysfunctions related to Stroke syndromes and Guillain Barre syndrome
b) Loss of sleep -Anosmia
c) Cognitive impairment related to ICU psychosis or due to prolonged ICU stay

4) Musculoskeletal System
a) Muscle Pains(myalgia), Muscle weakness, Joint pains (poly arthralgia), excessive fatigue may be experienced. Patients may complain of less energy levels to carry out daily routine

5) Mental Health
a) Anxiety’, Depression, Post-traumatic stress disorder and ICU psychosis are common as a result of post intensive care unit syndrome

6) Metabolic
a) New-onset Diabetes Mellitus
The physiotherapist should be aware and familiar with the clinical picture/ hospital stay and the physiotherapeutic intervention strategies. The physiotherapist should also be able to identify the need for referral to other disciplines such as psychologists and dietitians as needed. Some people (including children and older people) may not have the most commonly reported new or ongoing symptoms after acute COVID-19.

Section C:  Pre- Physiotherapeutic Intervention Screening and assessment for Physiotherapy interventions

It is important that all patients referred for physiotherapy should be screened prior, assessed and continuously monitored prior, during and after physiotherapy care.

C1 Pre-Physiotherapy Intervention Screening:

 C 1.1. Prior screening by checking the hospital/treatment records for any cardiovascular impairment in the form of myocarditis or ischemia or pulmonary thromboembolism duringhospital stay and related advice by the physician is mandatory. Patients with suspected post-Covid myocarditis, acute chest pain, pedal oedema, excessive sweating or any such signs of associated cardiac involvement or with raised inflammatory markers should immediately be referred to the concerned physician and should be attended only after the patient is completely asymptomatic of the cardiac symptoms and is ready/referred back for physiotherapeutic intervention. Similarly patients with symptoms of giddiness should be evaluated for the source of symptoms before enrolment  Associated primary system impairments of cardio respiratory, metabolic, musculoskeletal or neurological should be noted to facilitate special rehabilitative pathways

C 1.2. Associated co morbidities that would alter the course and path of physiotherapy physiotherapeutic intervention should be documented

C 1.3. Hemodynamic stability at rest and with mobility and exercise during the ward course and pre discharge should be noted from documented records.

C 1.4. Respiratory and oxygen support requirements for activity induced desaturation should  also be noted

C 1.5. Detailed evaluation for the course of disease when hospitalized or in quarantine  centers, along with related investigations and pharmacological management should be notedto facilitate the mode of Physiotherapy intervention.

C.2 Physiotherapy Assessment

It is recommended that a detailed Physiotherapy assessment to be done before beginning of a Post Covid Physiotherapy regime. Such an assessment should include the following

1) Detailed Demographic data which would include age, gender, residence, work,

2) Covid-19 History

Covid 19 History details should include :

a) Date of positive RTPCR.
b) Symptoms on diagnosis and categorization of severity.
c) Place of isolation whether quarantine centers, home, or hospital admission.
d) Hospitalization details including need of ICU stay, oxygen support, mechanical ventilation, NIV, HFNC, drugs, associated complications if any.
e) Investigations which would include CBC, Blood Sugar level and HbA1C, Inflammatory markers, enzymes, thrombogenicity, cardiac reports like ECG,echocardiography, respiratory system evaluation reports like X- Ray, HRCT, Last available ABG, PFT
f) Present symptomology since post covid and perceived activity limitations
g) Co-morbidities and preexisting Musculoskeletal or Neuromuscular disorders
h)Perceived activity limitations
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3) System Examination
System evaluation and examination should include
a) Resting and activity related vital parameters of HR, BP, SpO2
b) Respiratory system evaluation for
i. resting and activity breathing pattern
ii. Ventilation and presence of secretions as on auscultation
iii. use of oxygen support details
iv. degree of dyspnea as on MRC scale
v. breath holding capacity

c) cardiovascular system evaluation of change in heart rate and blood pressure with activity. Any associated symptoms of chest pain, excessive sweating or giddinesswould warrant discontinuation of activity  d)Musculoskeletal system.
i. Pain - Site, type, severity using VAS/NPRS
ii. Range of Motion assessment
iii. Myalgia and Muscle spasm
iv. Gait with/without assistive devices

e)Neuromuscular system
i. Balance and co-ordination assessment
ii. sensory assessment
iii. Paresthesia if present
iv. Manual Muscle Testing

4)Functional Assessment

a)Functional Capacity
i. 6 MWT

1. Avoided in case of tele physiotherapeutic intervention mode

2. If difficulty to walk for 6 minutes due to any cause, two-minute walk test or 40-meter walk test can be considered
ii. 30 second sit to stand or 1 minute sit to stand testiii. TUG for balance

b) Fatigue Assessment
i. Visual Analogue scale for Fatigue (VAS-F)
ii. Fatigue Severity Scale

c) Gross screening for Psychological impairment
i. Screen for anxiety and depression and if found appropriate, refer to the consultant

d) Nutritional Assessment
i. Weight Loss
ii. Loss of Muscle Mass
iii. BMI

Physiotherapist needs to tailor monitoring of people’s symptoms and discuss any changes, including new or worsening symptoms and the effects of these on the person's wellbeing.

Consider supported self-monitoring at homelike heart rate and blood pressure and pulse oximetry where feasible. Ensure that people have clear instructions and parameters for when to seek further help.

Physiotherapist needs to be alert to symptoms developing that could mean referral or investigation is needed.

Section D Physiotherapy Interventions:

It is advisable to opt for tailor made protocol which depends on severity of impairments and number of systems involved. Physiotherapy interventions should be directed towardsRespiratory exercises, Muscle endurance and strength training, energy conservation, functional independence and training and patient education. Intervention includes selection ofproper exercises and Exercise Prescription.

D.1 Physiotherapy Intervention.
D.1.1 Respiratory Exercises.

1) Improving Inspiratory Capacity and recruiting Diaphragm.

a) Inspiratory breath holds with an inspiratory hold for 3 seconds.
b) Diaphragmatic Breathing.

2) Breathing control and Pursed lip breathing.

3) Positioning - In patients with persistent breathlessness, prone positioning can be continued with adequate support for comfortable position and monitoring of vitals.

4) Airway Clearance techniques - for patients with retention of secretions or difficulty in expectoration.
a) Active Cycle of Breathing (ACBT).
b) Autogenic Drainage (AD).

5) Lung Volume Expansion Exercises
a) Chest expansion Exercises with proprioceptive feedback with emphasis on thoracic expansion
b) Thoracic expansion exercises and ribcage mobility in view of restrictive nature of the disease
c) Segmental Expansion Exercises
d) Incentive Spirometry - Single use device

6) Respiratory Muscle Training - it is recommended to avoid overloading the muscles during respiratory muscle training.
a) Inspiratory Muscle Training (IMT) - these device load respiratory muscles. 2 sessions of 10 minutes per week for six weeks.
b) Non-threshold load training for inspiratory muscles - started from 3 cm H2O and slowly increased thereafter, 10-15 minutes.
c) Cough etiquettes need to be practiced throughout.

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