key: cord-0974210-xbuqd0j5 authors: Felten-Barentsz, Karin M; van Oorsouw, Roel; Klooster, Emily; Koenders, Niek; Driehuis, Femke; Hulzebos, Erik H J; van der Schaaf, Marike; Hoogeboom, Thomas J; van der Wees, Philip J title: Recommendations for Hospital-Based Physical Therapists Managing Patients With COVID-19 date: 2020-06-18 journal: Phys Ther DOI: 10.1093/ptj/pzaa114 sha: e0156be7a10b02e13d30ea110571a01236760d10 doc_id: 974210 cord_uid: xbuqd0j5 OBJECTIVE: The COVID-19 pandemic is rapidly evolving and has led to increased numbers of hospitalizations worldwide. Hospitalized patients with COVID-19 experience a variety of symptoms, including fever, muscle pain, tiredness, cough, and difficulty breathing. Elderly people and those with underlying health conditions are considered to be more at risk of developing severe symptoms and have a higher risk of physical deconditioning during their hospital stay. Physical therapists have an important role in supporting hospitalized patients with COVID-19 but also need to be aware of challenges when treating these patients. In line with international initiatives, this article aims to provide guidance and detailed recommendations for hospital-based physical therapists managing patients hospitalized with COVID-19 through a national approach in the Netherlands. METHODS: A pragmatic approach was used. A working group conducted a purposive scan of the literature and drafted initial recommendations based on the knowledge of symptoms in patients with COVID-19, and current practice for physical therapist management for patients hospitalized with lung disease and patients admitted to the intensive care unit (ICU). An expert group of hospital-based physical therapists in the Netherlands provided feedback on the recommendations, which were finalized when consensus was reached among the members of the working group. RESULTS: The recommendations include safety recommendations, treatment recommendations, discharge recommendations, and staffing recommendations. Treatment recommendations address 2 phases of hospitalization: when patients are critically ill and admitted to the ICU, and when patients are severely ill and admitted to the COVID ward. Physical therapist management for patients hospitalized with COVID-19 comprises elements of respiratory support and active mobilization. Respiratory support includes breathing control, thoracic expansion exercises, airway clearance techniques, and respiratory muscle strength training. Recommendations toward active mobilization include bed mobility activities, active range-of-motion exercises, active (−assisted) limb exercises, activities-of-daily-living training, transfer training, cycle ergometer, pre-gait exercises, and ambulation. As of publication date, the number of patients with respiratory syndrome caused by coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID- 19) , is still increasing rapidly worldwide. Spreading of COVID-19 occurs mainly through respiratory droplets and aerosols produced when an infected person coughs or sneezes. 1 To our knowledge, there is currently no consensus on the period the virus is transmissible to other humans, however the duration and transmissibility seem to differ between patients with differing severity of illness. 2 Even after resolution of symptoms, individuals might keep shedding the virus. 3 Diagnosis of COVID-19 requires detection of SARS-CoV-2 RNA using a combination of nasopharynx-and throat sample. 4 ,5 SARS-CoV-2 RNA can also be detected in stool and blood. 4 Chest computed tomography (CT) images from patients with COVID-19 typically demonstrate bilateral, peripheral ground glass opacities. Unfortunately, this pattern is nonspecific and overlaps with other infections; therefore, the diagnostic value of chest CT imaging for COVID-19 may be low. 4, 5 Recent data from China and Italy indicate that in 80 percent of cases COVID-19 infection causes 'mild and moderate illness', approximately 15 percent of cases develop 'severe illness' leading to hospitalization, and 5 percent develop 'critical illness' requiring ICU treatment. 2, [4] [5] [6] Hospitalized patients with COVID-19 experience a variety of symptoms, including fever, muscle pain, tiredness, cough, and difficulty breathing. 7 Elderly people and those with underlying health conditions are considered to be more at risk of developing severe symptoms, 4 and have a higher risk of physical deconditioning during their hospital stay. 8, 9 Physical therapists have an important role in supporting hospitalized patients through respiratory support and active mobilization. Physical therapist management should be tailored to the individual patient's needs concerning frequency, intensity, type and timing of the interventions, in particular for those with severe/critical illness, >70 years of age, obesity, comorbidity and other complications. 10, 11 Yet, physical therapists need to be aware of potential challenges when treating patients with COVID-19. In a recent study, an international group of authors described the physical therapist management for COVID-19 in the acute hospital setting, including workforce planning, screening, delivery of physical therapist interventions and personal protective equipment (PPE). 12 In line with this international study 12 and the consensus statement of Italian respiratory therapists 13 we aim to provide guidance and detailed recommendations for hospital-based physical therapists managing patients hospitalized with COVID-19 through a national approach in the Netherlands. [H1] Scope This study focuses on adult patients admitted to the (acute) hospital setting due to COVID-19. In general, patients with COVID-19 experience the following signs and symptoms: fever (83%-99%), cough (59%-82%), fatigue (44%-70%), weight loss (40%-84%), shortness of breath (31%-40%), secretion production (28%-33%) and myalgias (11%-35%). 4, 6 Recent studies showed that illness severity can range from mild to critical: 2, [4] [5] [6]  Mild to moderate (mild symptoms up to mild pneumonia): 80%  Severe (dyspnea, hypoxia, or >50% lung involvement on imaging): 15%  Critical (respiratory failure, shock, or multiorgan system dysfunction): 5% Critical cases, needing ICU treatment, may show symptoms of Acute Respiratory Distress Syndrome (ARDS) like lung disease, with widespread inflammation in the lungs. 5 Consolidation lesions also remain at long-term and can leave fibrotic changes in the lungs. 5 Furthermore, patients who are critically ill, needing ICU treatment, are at risk of developing post-intensive care syndrome (PICS) including ICU-acquired weakness (ICU-AW). [13] [14] [15] Mortality among patients admitted to the ICU ranges from 39% to 72%. 4 Health care professionals should be aware that the clinical progression of symptoms might occur one week after illness onset. 5, 13, 14 Important subgroups are elderly people (≥70 years of age) and those with underlying health conditions (eg, hypertension, diabetes, cardiovascular disease, chronic respiratory disease and cancer), who are considered to be more at risk of developing severe symptoms, 4 but also at risk of physical deconditioning during hospital stay. 8, 9 Figure 1 is based on recent literature and shows the flow of patients with COVID-19 with their signs and symptoms before 4,6,7 and during hospital admission; 4,5,7-9,13,15,16 the severity classification 2,4-6 and the physical therapy goals during hospital stay. [10] [11] [12] [13] 17 These recommendations focus on the physical therapist management for adult patients with COVID-19 admitted to the (acute) hospital setting. Recommendations contain specific physical therapy goals concerning respiratory problems and deconditioning including ICU-AW and PICS. The recommendations are outlined in 2 sections:  Section 1: Patients who are critically ill with COVID-19 admitted to the ICU.  Section 2: Patients who are severely ill with COVID-19 admitted to the COVID ward. We used existing international recommendations 12,13 as basis for further specification and contextualization. When our recommendations diverge from the international recommendations, we clarified this in the main text and through a separate paragraph with reflections. The recommendations are structured in the following 6 order: safety recommendations, treatment recommendations (specified for different phases of hospitalization), discharge recommendations, and staffing recommendations. Due to the acute and sudden spreading of COVID-19, the evidence base for optimal treatment for this group of patients is evolving rapidly and new insights are emerging at a similar pace. Nevertheless, clear recommendations for hospital-based physical therapist management, either based on evidence or bestpractices, are crucial to support the recovery of patients and safety of health care professionals. These recommendations will be updated periodically based on new evidence and experience, and will be made available through the website of the Royal Dutch Society for Physical Therapy and the World Confederation for Physical Therapy. To cope with this rapidly evolving evidence base, we utilized a pragmatic approach, rather than a formal approach (such as GRADE), 18 Respiratory droplets and aerosols may be released from patients during physical therapist interventions and may cause further spread of the virus. Direct contact between physical therapists and patients with COVID-19, therefore, should be minimized to avoid risk of virus transmission and reduce usage of scarce PPE. Therefore, we recommend physical therapists make optimal use of telecommunication and written information material. If direct (face-to-face) contact with patients with COVID-19 is required, physical therapists should use PPE. Recommended PPE include a gown, gloves, eye protection and a facemask. 4  Active mobilization, which may lead to coughing and secretion mobilization or disconnection of the mechanical ventilation. If one of the above procedures is performed, physical therapists are recommended to wear a facemask that filters at least 95% of airborne particles (ie, FFP2 mask, N95 facemasks). Physical therapists should ensure that they are fully competent in the use of PPE. 4 Safety recommendations need to be taken into account during all  Recommendation: Make optimal use of digital and/or written information for the instruction of patients. Physical therapist management for patients hospitalized with COVID-19 comprises elements of respiratory support and active mobilization. 20, 21 Recommendations toward respiratory support, defined as the "proactive approach to minimize respiratory symptoms during the acute phase of a pulmonary disease," 22 are presented in detail. In the treatment of patients with COVID-19, respiratory support can consist of breathing control, thoracic expansion exercises, airway clearance techniques and respiratory muscle strength training. Recommendations toward active mobilization concern the "proactive approach to support any physical activity where patients assist with the activity using their own strength and control: patients may need assistance from staff or equipment, but they are actively participating in the exercise." 21 Examples of active mobilization are bed mobility activities (eg, bridging, rolling, lying to sitting), active range-of-motion exercises, active (-assisted) limb exercises, ADL training, transfer training, cycle ergometer, pre-gait exercises, and ambulation. [H3] Phase A: patient is unconscious-respiratory support. Patients with critical illness due to COVID-19 may develop acute respiratory distress syndrome (ARDS)-like symptoms, requiring admission to the ICU. 24 Initially, the majority of patients are deeply sedated (RASS ≤ -4) and mechanically ventilated in prone position. 25 These patients often receive neuromuscular blocking agents in order to support mechanical ventilation, as this drug application can improve chest wall compliance, eliminate ventilator dyssynchrony, and reduce intraabdominal pressures. 26 Given the lack of therapeutic goals in this phase, physical therapist management concerning respiratory support is not recommended. This might be different for physical therapists outside the Netherlands with other scope of practice concerning respiratory support. [H3] Phase A: patient is unconscious-active mobilization. [H3] Phase B: patient is conscious and able to cooperate-respiratory support. The moment sedation is reduced (RASS ≥ -2) and the patient is conscious and able to cooperate (S5Q ≥ 3), a new phase starts. 25 Normally, this is the phase to start active mobilization and respiratory support; however, in patients with COVID-19, detachment of the closed mechanical ventilation system circuit should always be avoided due to the risk of virus transmission. Even in the case of weaning from mechanical ventilation, where physical therapists typically aim to ensure sufficient inspiratory muscle strength, 29,30 the risk of virus transmission via droplets or aerosols in using medical assistive testing devices is too high. Therefore, we recommend to not detach the ventilation system for the purpose of respiratory function testing, respiratory muscle training, or breathing exercises. 19 To our knowledge, it remains unclear if both droplets and aerosols are filtered by disposable bacterial filters. 31 In case of prolonged weaning, patients who fail more than 3 weaning attempts or require more than seven days of weaning after the first spontaneous breathing trail, 32 respiratory muscle training should be discussed in the multidisciplinary team. 30 The team may decide that benefits of respiratory muscle training outweigh the safety risks. In the phase after prolonged (assisted) mechanical ventilation, inspiratory (IMT) and expiratory muscle training (EMT) can be used to counterbalance the weakness of the respiratory muscles. 29 36 However, the use of these devices is not recommended in patients with COVID-19 due to the increased risk of virus transmission. In this situation, training can be started pragmatically (ie, without respiratory testing results) using a threshold training device, with low resistance (< 10 cmH2O) and can be increased based on clinical presence, experienced dyspnea and BORG score for perceived exhaustion. 37 For respiratory muscle strengthening, a combination of both IMT and EMT is recommended, as this combination is superior to IMT alone in improving respiratory muscle strength. 33 As respiratory muscle training devices could carry the virus (prolonged), the use of these devices should be discussed with hospital officers for hygiene and infection prevention. Recommendation: Discuss with the multidisciplinary team whether to pragmatically initiate respiratory muscle strengthening in patients with prolonged weaning. [H3] Phase B: patient is conscious and able to cooperate-active mobilization. When patients become conscious and cooperative, active mobilization can be considered. Active mobilization should aim to prevent ICU-AW and deconditioning from immobilization and illness. The Medical Research Council Sum-Score (MRC-SS) is widely used to diagnose ICU-AW, which is defined as an MRC-SS < 48. 38 It is assumed that patients diagnosed with ICU-AW may benefit from active mobilization also following their ICU admission. physical activities for patients who are critically ill should be planned and targeted following the evidence based statement for physical therapist management in the ICU as much as possible. 17 Patient safety criteria according to Sommers et al. 17 for active mobilization that always need to be considered at the ICU, are presented in Figure 3 . Close monitoring of respiratory and hemodynamic functions of patients is crucial to ensure patients' safety. 17, 21 As a first step, bed mobility activities can be performed by assisting bridging, rolling, and transferring from supine to sitting. 23 Medical assistive devices (eg, a bed cycle) might be used to support active mobilization. However, use of these devices should be discussed with hospital officers for hygiene and infection prevention. To evaluate and increase training intensity, frequency and/or activities, criteria of American College of Sports Medicine (ACSM) guidelines for exercise testing and prescription, 40 Ideally, the physical therapist is the leading health care professional to guide active mobilization. However, safety recommendations can also be decisive in initiating physical therapist management. If safety recommendations for health care providers do not warrant direct physical therapy contact, we recommend to instruct nurses to combine active mobilization with daily care activities. In this case the physical therapist has a coaching role. Patients who are severely ill with COVID-19 who require hospitalization can present with complications such as pneumonia, hypoxemic respiratory failure/ARDS, sepsis and septic shock, cardiomyopathy and arrhythmia, acute kidney injury, and complications from prolonged hospitalization, including secondary bacterial infections. 4 Because the consequences of the infection impact the respiratory system, one of the goals of physical therapist management is to optimize respiratory function. Therefore, respiratory support aims to improve breathing control, thoracic expansion, and mobilization/evacuation of secretion. Active mobilization aims to increase (or maintain) physical functioning and independence in activities of daily living (ADL). These recommendations also apply for patients recovering from critical illness due to COVID-19. Additionally, in patients recovering from critical illness respiratory muscle strength/endurance training can be continued. [H3] Respiratory support. Respiratory support serves several purposes: to improve vital capacity, to evacuate secretion, and to strengthen respiratory muscle. Techniques and goals are briefly introduced as follows: 13 breathing control and thoracic expansion exercises, and combines these with huffing and coughing. 41, 42, 45 Huffing and coughing contribute to the formation of respiratory droplets and aerosols and should be avoided in direct contact with health care professionals. Therefore, these maneuvers are only recommended in case of airway obstruction due to excess secretions. The multidisciplinary team should carefully evaluate whether airway obstruction is present through medical history taking (eg, the presence of productive cough), physical examination (eg, the presence of pulmonary rhonchus), and observations. Telecommunication and/or written instruction material can be used to support the use of ACBT. If patients fail to effectively use ACBT, teaching these techniques under direct supervision of a physical therapist can be considered.  Strengthening of respiratory muscle: Patients with COVID-19 might have suspected respiratory muscle weakness caused by prolonged mechanical ventilation during ICU stay. After transfer to the COVID ward, respiratory muscle strengthening can be continued for patients recovering from critical illness according to the recommendations in Section 1, Phase B. Training protocols typically use resistive loads ranging between 30% and 80% of MIP. 46 However, the use of noninvasive handheld manometers is not recommended in patients hospitalized with COVID-19 due to the increased risk of virus transmission. According to Section 1, Phase B, training can be started pragmatically (ie, without respiratory testing results) using a threshold training device with low resistance (< 10 cmH2O), and can be increased based on clinical presence, experienced dyspnea and BORG score for perceived exhaustion. 37 One of the unique advantages of respiratory muscle training is that it can be implemented in shorter intervals (30 breaths, 2 times/day). Training effects from respiratory muscle training have been observed for multiple protocols lasting only 4 weeks. 46 A telehealth or mobile app- [H3] Active mobilization. If patients are bedridden and suffering from COVID-19, pulmonary ventilation can be stimulated by bed mobility activities through bridging, rolling, and sitting. 11 If possible, patients might assist with their own strength and control. If needed, staff and equipment can be used to support the activity. A vertical position can be obtained with less support of patients by tilting the bed or using a tilt table. In order to prevent further deconditioning, patients should be stimulated to be physically active through active mobilization as much as possible through the hospitalization period. Physical therapists can provide specific exercises and training that meet the needs and preferences of patients with COVID-19. Maintaining or improving physical functioning should be executed following common safety recommendations, monitoring, and guidance. 17, 21 Based on our expert opinion, at least patient's saturation and heart rate should be monitored before and during active mobilization, due to the low and fluctuating vital capacity of patients with COVID-19. Active mobilization interventions that need to be considered are bed mobility activities, active range of motion exercises, active(-assisted) limb exercises, ADL training, transfer training, cycle ergometer, pre-gait exercises, and ambulation. 23 The hospital-based physical therapist should screen patients with severe illness due to COVID-19 on whether physical therapist management should be continued after hospital discharge. 48 19 Hospital-based physical therapists with these skills and knowledge should be tasked with training of less experienced colleagues to provide them with the necessary skills, knowledge and self-confidence for physical therapist management of patients with COVID-19.  Recommendation: Deploy physical therapists with sufficient skills, knowledge and self-confidence in care for patients who are severely ill at a COVID-19 ward or in the ICU. The COVID-19 outbreak presents new challenges for health care professionals. Physical therapists will work intensively with patients who are severely ill, which can lead to mental health distress. It is recommended for managers to plan sufficient recovery time between work shifts of physical therapists and to let less experienced colleagues carefully be supervised by experienced peers. In these turbulent times, provision of psychosocial support should be considered.  Recommendation: Provide psychosocial support for hospital-based physical therapists. In this manuscript we provide detailed recommendations and intervention descriptions for hospital-based The Royal Dutch Society for Physical Therapy (KNGF) supported the development of the recommendations. The Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia COVID-19 and Italy: what next? Lancet Time Kinetics of Viral Clearance and Resolution of Symptoms in Novel Coronavirus Infection. 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