Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19

Article Reviews
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Read Full Text: Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19 (Free to access)
Journal: American Journal of Physical Medicine & Rehabilitation
Year Published: 2020
CEU Podcast: COVID-19 and OT with Torrie Niewohner

There are currently no set guidelines on COVID-19 rehab. But, there are definitely some trends emerging from the research.

What we do know is it’s super high priority to get these patients moving (without their O2 saturation dropping in the process). Doing so helps keep the lungs clear and helps support other systems throughout the body.

This week, we’ll look at a research analysis that focused on physical rehab and pulmonary rehab (which, of course, go hand in hand).

I know we say this at OT Potential a lot, but your skill set is desperately needed to help patients recover from COVID-19, and return to the lives they love.

Let’s dive in.

Who wrote this paper and why we chose it

As OTs, we are always balancing a general therapeutic approach with disease-specific considerations.

With COVID-19 being a novel (new) virus, we’re still figuring out the specifics for rehab programs. But, there’s at least one thing we can all agree on: we should avoid interventions that cause patients’ O2 saturation to drop too low.

That’s why we chose this particular research analysis—it focuses heavily on respiratory concerns. The paper is written for physical medicine and rehabilitation physicians, but it does a good job of laying out the concerns and disease management principles the entire rehab team should keep in mind.

General principles for COVID-19 rehab

We won’t go into this in depth here, but preventing the spread of COVID-19 is obviously of utmost importance. The paper leads by reinforcing that telemedicine and minimal contact interventions are preferred, whenever possible. It then delves into different severity cases and corresponding rehab considerations.

Outpatient management of mild COVID-19 cases

This article defines “mild COVID-19” as exhibiting mild symptoms, without showing pneumonia manifestations on imaging. This disease severity is best managed in the outpatient/home setting.

Here is the rehab that is proposed for this mild COVID-19:

Patient education

  • Encourage good lifestyle habits like adequate sleep, hydration, proper nutrition, etc.

Physical activity recommendations

  • Exercise intensity: Borg Dyspnea Scale score ≤3
  • Exercise frequency: 1-2 times per day, 3-4 times a week
  • Exercise duration: 10-15 mins for first 3-4 sessions and incrementally increase. 15-45 min each session
  • Exercise type: walking, biking
  • Progression: incrementally increase workload/effort every 2-3 sessions to target Borg Dyspnea Scale score 4-6 and target total duration to 30-45 mins

Psychological intervention

  • Counsel about social support
  • Provide resources including professional psychiatric professionals

Airway clearing

  • Expectorant hygiene into closed container to prevent aerosolization of sputum
  • Huff cough

Breathing exercises

  • Techniques: diaphragmatic breathing, pursed-lip breathing, active abdominal contraction, yoga, pranayama, Tai Chi, singing
  • Frequency: 2-3 times/day, daily
  • Duration: 10-15 mins for first 3-4 sessions
  • Progression: incrementally increase duration every 2-3 sessions towards a total goal duration of 30-60 mins

OT Potential Notes:

I know the Borg Dyspnea Scale might be new to you, but it is super easy for you and your patients to use, and if you reference it during your OT sessions, you’ll hopefully be reinforcing what other members of your team are doing.

Also, Johns Hopkins has a REALLY GREAT handout that breaks down the exercise and breathing components even more thoroughly—and it really emphasizes safety! (As noted a few times already, we do NOT want O2 saturation to drop too much during exercise.) Every team member should be reinforcing the importance of safe movement.

https://www.hopkinsmedicine.org/physical_medicine_rehabilitation/coronavirus-rehabilitation/_files/impact-of-covid-patient-recovery.pdf

Acute inpatient management of COVID-19 cases

Moderate to severe disease is seen in patients approaching respiratory distress. This means a respiratory rate over 30x/min or O2 saturation below 93% at rest. These patients require hospitalization and monitoring.

Early mobilization in the ICU needs to be approached with cautious consideration, and it should never occur at the expense of healthcare worker safety.

Here is the rehab that is proposed for moderate to severe COVID-19:

Patient education

  • Educate patient about individual statistics based on comorbidities and clinical course of the disease
  • Educate patient about the importance of posture and accessory muscle use
  • Education regarding nutrition and weight

Activity recommendations

  • Exercise intensity: Borg Dyspnea Scale score ≤3
  • Exercise frequency: 2x/day, daily
  • Exercise time: 10-15 mins first 3-4 sessions
  • Exercise type: bed mobility, sit to stand, ambulation, breathing rehabilitation exercises, yoga, Tai Chi
  • Progression: incrementally increase workload/effort to Borg score 4-6 and duration to 30-45 mins every 2-3 sessions

Psychological intervention

  • Counsel about social support and encourage phone calls and communication with family
  • Consult professional psychiatric services as necessary

Airway clearance

  • Expectorant hygiene into closed container to prevent aerosolization of sputum
  • Airway clearance techniques as needed

More on physical exercise, stretching and breathing
Physical exercise is a cornerstone of pulmonary rehab, as it has been shown to facilitate airway clearance. Early mobilization and physical exercise are more effective than other mucus clearance techniques, which is why it’s so critical that we get patients up and moving if it’s safe for them.

That being said, initial exercise should always be graded and approached with caution and monitoring. Here’s the exclusion criteria, meaning you should not exercise a patient if they:

  • Have a temperature greater than 100.4 F
  • It is 3 or less days since initial diagnosis or onset of symptoms
  • It is 3 or less days since initial onset of dyspnea
  • Have SpO2 of 90% or less
  • Have a respiratory rate of greater than 40 beats per minute
  • Have a heart rate of of less than 40 beats per minute or greater than 120 beats per minute
  • Show new onset of arrhythmia and myocardial ischemia
  • Demonstrate altered state of consciousness

During exercise, you should target a SpO2 of greater than 90% (with titration of supplemental oxygen as needed and when appropriate). Activity should be paused if O2 saturation drops below 90%, at which point a breathing technique like pursed-lip breathing should be used until O2 again reaches 90%.

The article also notes that patients should be encouraged to engage in routine stretching 3x/day. Stretches should include neck, upper chest, pectoralis major, lateral chest stretches, and flexion and extension to mobilize the facet joints.

Again, this John Hopkins handout does an awesome job describing this in even more detail!

https://www.hopkinsmedicine.org/physical_medicine_rehabilitation/coronavirus-rehabilitation/_files/impact-of-covid-patient-recovery.pdf

Positioning

Finally, positioning is a simple and effective way to help keep lungs clear. Sitting and standing are the preferred positions in non-critically ill patients to maximize lung capacity.

That said, authors recommend frequently switching positions when lying in bed, spending time side lying, upright, supine, and prone. Each position contributes to helping to clear different areas of the lungs. (The article gives a good overview of how positioning can even target different areas of the lung.)

Post-acute COVID-19 rehab

Inpatient acute rehab should be individualized to the patients needs.

However, the authors go on to recommend that outpatient pulmonary rehab should be considered for all patients who have been hospitalized for COVID-19. They specifically give a shout-out to OT and PT, which should be considered for residual functional deficits associated with prolonged hospitalization.

One of the main goals of outpatient rehab should be working toward improvement in exercise capacity. During exercise, the target spO2 may range from 85% to 90%, with supplemental O2 as needed. (Typically, normal exercise SpO2 is 88-92%. However, in this population, tolerated desaturation may be as low as 85%, as long as there is no other change in vitals and they have a rapid recovery once activity ceases.)

Recommended further reading

I just want to give another shout-out to the COVID-19 rehab resources being provided by Johns Hopkins.

I found this special communication from the American Congress of Rehabilitation Medicine to be a really helpful read:

https://www.sciencedirect.com/science/article/pii/S0003999320309369

Takeaways for OT practitioners

1.) Your priority: help COVID-19 patients keep moving SAFELY

As an OT, you may be with a patient when they are engaging in activity or exercise for the first time, and it is important to help them monitor what they can do safely without their oxygen levels dropping. Help them recognize when their levels are dropping or they are getting too high on the Borg Dyspnea scale.

Then, in the outpatient setting, focus on helping them build their activity and exercise capacity to pre-COVID-19 levels.

2.) There is a lot more to discuss with COVID-19 rehab!

COVID-19 is a rapidly evolving situation. If you encounter new research you think we should be discussing in the Club, never hesitate to reach out to me. I really want to find an article to focus on the long-term impacts of COVID-19 and how we should be prepared to help.

3.) Take care, you

I know this is a stressful time. And, your skill set is needed both at work and on your home front. Please take time to exercise, laugh, sing, and hum—anything you do to keep your lungs and yourself healthy :slight_smile:

We’ll get through this.

Here’s the full APA citation for this article:

Wang, Tina J. MD; Chau, Brian MD; Lui, Mickey DO; Lam, Giang-Tuyet MD; Lin, Nancy MD; Humbert, Sarah MD Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19, American Journal of Physical Medicine & Rehabilitation: September 2020 - Volume 99 - Issue 9 - p 769-774

doi: 10.1097/PHM.0000000000001505

Earn one hour of continuing education by listening to the podcast on this article!!

In this podcast episode, we dive even deeper into this topic, with COVID-19 expert (and Club member!), Torrie Niewohner. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!

What questions/thoughts does this article raise for you?

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wow this is such timely important information!! Love the John Hopkins handout. I will be able to use this for all my patients with any type of breathing issue. I have found in my home health treatment that when I have patients that have breathing issues and become SOB easily that if I incorporate arm movements with any type of breathing coaching it helps them slow down there breathing. I either use a yoga stretch type of breathing with arm sweeps up and over the head or my favorite is having them place their arms on their chest then stretch their elbows back as they inhale and push them in as they exhale. My patients seem to grasp this one the quickest. I pair this with education on the importance of breathing slowly and deeply to get the O2 down to the bottom of their lungs for air exchange and making sure they exhale deeply to get the CO2 out. This seems to make the most sense to them. In home health trying to couch training in terms that make sense to a layperson makes a huge difference.

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This is so helpful! I especially appreciate the hand out! It lays out a really clear path forward. My biggest concern right now with Covid pts other then what was mentioned in this article is cognition. I’ve had a few people who were impacted cognitively and info regarding interventions that are especially relevant for this population would be great! I’ve been working from a comp and rehab perspective for most of my patients since they are in their home and I need to ensure they are safe without supervision. I’ve noticed difficulties with memory and processing speed, but I have only had a handful of COVID pts so I’m not sure of that is typical.

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Thank you for this very informative article. I have worked in the homehealth care and hospital setting. The specific categorization of pulmonary requirements for patients will surely assist doctors and clinician in their decision whether to send patients home or let them continue to get medical care in the hospital.

This article vividly outlines clinical signs and symptoms clinicians need to put into consideration when formulating their plan of care. It also gives practitioners insight on how to update their treatment plans with patients who have Covid-19 cases.

Thank you for for sharing this article.

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I have worked with COVID-19 patients in SNF and in the LTACH setting. Sometimes the basics of educating and performing simple bed to wheelchair transfers are the most they can handle but so important for movement. Mostly incorporating pursed-lip breathing and techniques to cope with anxiety with their SOB. For patients on ventilators, simple bed mobility and gentle AROM/PROM is helpful. To help with patients’ cognition and mental health it’s best to be empathetic and slow down the therapy process and go at their speed.

This information was very helpful to think of other breathing and light exercises to increase vestibular, breathing, and movement for the whole body. I have never used the Borg Dyspnea scale but it is as simple as the pain scale which many patients are familiar with and to get a subjective measure that can be used in documentation everyday.

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Thank you for a very informative and timely article. The step-by-step guide from Johns Hopkins Rehab on breathing exercises is very helpful. I am going to include this info in my module on COVID-19 for students. I think it will be very helpful for students to have this knowledge when they go for their FW and also their first job. The effects of COVID-19 appear to be long-standing and ever-evolving.
It was interesting to learn that in outpatient rehab, the tolerated desaturation in this population may be as low as 85% as long as there is no other change in vitals and they have a rapid recovery once activity ceases. These guidelines will help clinicians to monitor and continue therapy even with subliminal O2 sats.
I found this article in the Journal of Psychiatry, which reveals that cognitive impairments exist even in patients recovered from COVID-19, and might be possibly linked to the underlying inflammatory processes (Zhou, Lu, Chen, Wei, Wang, Lyu, Shi,& Hu, 2020).

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@sheila1
There are studies that state that cognitive deficits are seen as long-term effects in COVID-19. Some of the tests used in one study were trail-making, digital span test, and others (which I am not familiar with). Which cognitive assessments are you utilizing for your clients? SBT, MoCA?

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Hey @sheila1! What you are seeing in practice definitely reflects what I’ve been reading about. The Harvard Health article I’m linking below is the best overview I’ve read of the long-term cognitive effects.

Honestly, reading the Harvard Health article is what pushed me to find this this article of the week that focused on respiratory concerns, because the lack of oxygen in the acute phase seems to be a contributor to long term brain damage.

@sheila1 and @dawn2, I’m curious if the patient you are seeing the home have their own pulse oximeter? It seems to me like every COVID patient should have one!

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This article article was very informative! One question it raises for me is the patient’s ability to participate in ADL and IADL tasks. I see a large need for us as OT’s to be educating the recovering COVID-19 patient in energy conservation techniques during these activities. Should they be educated in how to monitor their oxygen levels while doing these tasks to know when they are below acceptable levels to know when to stop and engage in the breathing techniques to bring their levels back up again. This article definitely had me thinking about how OT’s role would look in rehabilitation of this diagnosis. I also found the John Hopkins article very useful and thought provoking in my work as a school based pediatric OT. I could see how those breathing techniques and movement exercises could also benefit my students who struggle with posture and often do not use adequate diaphragmatic breathing patterns. Thanks so much for sharing that!

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@emily12, have you been reading about POTS emerging secondary to COVID? I don’t subscribe to the WSJ, but will just to read this article, unless you know a better source…

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Hi Sarah,

Thanks for the tag. Yes, absolutely we are seeing it and the research is showing around 25% of patients developing some sort of post-Covid dysautonomia (post-viral so it is logical) such as POTS. Dr Fauci has been cited saying they’re seeing symptoms –
“We do know for absolutely certain that there is a post-COVID syndrome,” Dr. Fauci said. “Anywhere from 25% to 35%—or more—have lingering symptoms well beyond what you would expect from any post viral syndrome like influenza and others. It’s fatigue, shortness of breath, muscle aches, dysautonomia, sleep disturbances and what people refer to as brain fog,” he said, or an inability to focus or concentrate… That can last anywhere from weeks to months,” he explained. Cardiologists also report that even among asymptomatic COVID patients, about 60% have some indication of inflammation of the heart which may or may not have a future effect on cardiac health.”

Dysautonomia international is doing a survey study right now to try and learn more about incidence and symptomatology.

Here are a few other articles. OTs should definitely be checking for orthostatic intolerance in post-Covid patients! That includes checking HR with positional changes, not just O2 sat or BP :slight_smile:

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Wow, these are really good reads! I haven’t even told you this, but I wanted to do a podcast episode next year on OT and POTs…I also wanted to do one on the long-term impact of COVID…I never dreamed they could be combined into one episode…

I’m going to send you an email today about starting to put the materials together!

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Great timely article. I learned a lot, blew off a few cobwebs from my acute care days, and have pasted on the resources to peers. The Hopkins Exercises are well done and easy to follow.
thanks,
Sherry

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Wow-oh-wow. This is bound to be a career shifting article for me, so thank you. I work in home health and am beginning to see an increase in patients who are either beginning to test positive in their own homes (already on caseload) or are coming out post-Covid19. The guidelines are especially helpful to me as I have been targeting energy conservation with activity modifications. I use the Short Blessed Test as a time saver and baseline for cognition (good question @sanchala).

Yesterday with a post Covid client, the focus was on using the Borg scale with a client to help him understand that the goal was not just “to shower” or “make a meal” but to do so at a Borg of 3 or less using energy conservation strategies (and keep his O2 >90%). This alone has been a new challenge to help clients understand/breakdown their goals into bite sized pieces.

What I am most excited about integrating is more of the guidelines… really tracking how they tolerate 15 min of sitting activity, then standing activity, etc. to progress to the 30-45 min of straight activity without elevating RPE/Borg scale or desaturating in oxygen levels (via the pulse ox readings) or increasing too greatly with HR.

What “wins” have folks had in using these strategies with clients who have had Covid19? I have been using the energy conservation handouts from the OT Toolkit and clients seem to be responding well. What are you most eager to try based on this new information?

I aim to objectively assess functional performance with the RPE/Borg scale, HR and O2 levels especially during simulated toileting and shower movements at the eval to help catch a functional baseline in these high risk and high priority areas of function. What a humble gift to be of service right now in healthcare to these clients and their families. THANK YOU so much for this information!

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