key: cord-1026451-ure4z0om
authors: Mayer, Kirby P; Steele, Angela K; Soper, Melissa K; Branton, Jill D; Lusby, Megan L; Kalema, Anna G; Dupont-Versteegden, Esther E; Montgomery, Ashley A
title: Physical Therapy Management of an Individual With Post-COVID Syndrome: A Case Report
date: 2021-03-18
journal: Phys Ther
DOI: 10.1093/ptj/pzab098
sha: 32440c14ce897c6676efd647d2f46a81c5df65e5
doc_id: 1026451
cord_uid: ure4z0om

OBJECTIVE: The purpose of this case report is to present the clinical presentation and physical therapist management for a patient with post–COVID syndrome. Secondarily, the report highlights the importance of assessing cognitive and emotional health in patients with post–COVID syndrome. METHODS (CASE DESCRIPTION): A 37-year-old woman tested positive for SARS-CoV-2 and developed mild COVID-19 disease but did not require supplemental oxygen or hospitalization. The patient experienced persistent symptoms including dyspnea, headaches, and cognitive fog. On day 62, she participated in an outpatient physical therapist evaluation that revealed deficits in exercise capacity, obtaining 50% of her age-predicted 6-minute walk distance (6MWD). She had minor reductions in muscle strength and cognitive function. Self-reported quality of life (QoL) was 50, and she scored above established cut-off scores for provisional diagnosis of posttraumatic stress disorder (PTSD). RESULTS: The patient participated in biweekly physical therapist sessions for 8 weeks, which included aerobic training, strengthening exercises, diaphragmatic breathing techniques, and mindfulness training. Metabolic equivalent for task (METS) levels increased with variability over the course of the program. The patient’s muscle strength, physical function, and exercise capacity improved. 6MWD increased by 199 m, equating to 80% of her age-predicted distance. QoL and PTSD scores did not improve. At evaluation after physical therapy, the patient was still experiencing migraines, dyspnea, fatigue, and cognitive dysfunction. CONCLUSION: This case report described the clinical presentation and physical therapist management of a person with post–COVID syndrome, a novel health condition for which little evidence exists to guide rehabilitation examination and interventions. Physical therapists should consider cognitive function and emotional health in their plan of care for patients with post–COVID syndromes. IMPACT: This case alerts physical therapists to post–COVID syndrome—which can include debilitating symptoms of decreased aerobic tolerance, anxiety, PTSD, and cognitive dysfunction—and to the role that therapists can play in assessing these symptoms and managing these patients.

Impact. This case alerts physical therapists to post-COVID syndrome-which can include debilitating symptoms of decreased aerobic tolerance, anxiety, PTSD, and cognitive dysfunction-and to the role that therapists can play in assessing these symptoms and managing these patients.

Individuals testing positive for SARS-COV-2 may have asymptomatic presentations or develop COVID-19 disease ranging from mild to severe presentations. Significant research and media attention have been given to patients that develop critical illness due to severe COVID-19 and require an intensive care unit (ICU)

admission. 1 More recently there have been numerous reports of non-critically-ill presentations of COVID-19

developing persistent and debilitating symptoms. 2, 3 Clinicians and researchers are actively studying disease trajectories and recognize an immediate need for "more sophisticated categorization of post-COVID-19

symptoms, including by precise etiology, as this will impact on treatment and rehabilitation decisions." 4 Recent guidelines recognize "two definitions of post-acute COVID-19 are given: (1) ongoing symptomatic COVID-19

for people who still have symptoms between 4 and 12 weeks after the start of acute symptoms; and (2) post-COVID-19 syndrome for people who still have symptoms for more than 12 weeks after the start of acute symptoms." 5 A few terms have been introduced to describe persistent symptoms following COVID-19 disease including "post-COVID syndromes" and "Long COVID." 3 The purpose of this case report is to present a patient with COVID-19 disease who never required hospitalization that developed persistent symptoms. We will describe physical therapy management to address symptoms of deconditioning, dyspnea and weakness, and we will explore the importance of assessing and addressing deficits in cognitive function and emotional health.

The patient was a 37-year-old female with no contributing past medical history, who had a positive test on SARS-CoV-2 testing performed routinely by her employer (Day 0). The patient reported a history of anxiety and depression, otherwise she was a healthy and active individual employed full-time as a nurse in an outpatient clinical center. Of importance to this case, the patient was a trail runner and completed 23 11 She also had reductions in lower-extremity (LE) muscle power as measured by unilateral leg-press 12 and time to complete five-time sit-to-stand test. 13 She presented with difficulty in multi-task performance measured by the difference in timed-up and go (TUG) test with cognitive component (34% difference) 14 and scored a 27/30 on Montreal Cognitive Assessment (MOCA) 15 missing three points for deficits with delayed recall. In addition, the patient's self-reported scores on Impact of Events Scale-Revised (IES-R) 16 were indictive of high levels of distress meeting criteria for provisional diagnosis of post-traumatic stress disorder with hyperarousal being the highest subcomponent (Table) . The patient's self-reported health-related quality of life was 50/100 on the EQ-5D-5L Visual Analog Scale. 17 The patient had a 50% deficit in 6-minute walk distance compared to her predicted distance which equates to 312 meters with modified BORG 18 rating of perceived exertion scale of 6

with SpO 2 ranging from 92-98%. 19

The patient has deficits in exercise capacity/aerobic endurance, minor reductions in muscle strength and power, and impairments in emotional health and cognitive function. Thus, the patient agreed to participate in

bi-weekly sessions for 8 weeks (16 sessions) of physical therapy treatment starting 64 days after her initial positive test. The outpatient rehabilitation program including the duration was based on active research at our institution and previous literature in patients surviving an ICU stay. 20, 21 In addition, the physical therapy plan of care was developed to gradually promoted increased physical activity at home as well as consideration for symptoms of distress, PTSD and anxiety related to COVID-19.

The patient attended 15 sessions with (94% attendance, one session missed due to gastrointestinal symptoms) with each session lasting 40-80 minutes. Interventions delivered during treatment and the physiological variables are presented in Figure 1 . Rehabilitation sessions were structured to include aerobic training, strength training, and breathing techniques with mindfulness training, and education.

Aerobic training duration and intensities were established based on performance of the six-minute walk. The patient's initial level for aerobic training was determined using calculation of 60-80% of peak heart rate during 6MWT accounting for heart rate reserve as defined by the Karvonen method. 22, 23 Aerobic intensity was progressively increased to maintain workload based on mRPE scale with goal intensity of 4/10 (somewhat hard) and not exceeding 6/10 (Hard). Based on performance on 6-MWT test with peak heart rate of 98 bpm the initial training range was set at 1.5-2.5 METS with heart rate range of 78-86 bpm. The initial aerobic intensity, may be considered low to moderate intensity, was selected as conservative approach with patient having active symptoms and risk of cardiac involvement post COVID. In addition, the patient was highly trained prior to COVID-19 disease and such has a lower peak heart rate was observed during testing. Aerobic exercises included recumbent upper extremity bicycle ergometer (UBE), recumbent cross-training stepper, treadmill walking and jogging as well as dancing (Fig. 1) during recumbent stepping on the second physical therapy session (Fig. 1) . Patient's mean and peak MET levels as well as peak HR and mRPE had a varied progression over the course of 8-weeks (Fig. 1) .

Strengthening training was prescribed based on mRPE with initial rating of 5-6/10 performing 10-15 repetitions as per guidelines for deconditioned patients. 24 Patients perform 10 to 20 minutes of resistance training with exercises focused on the major muscle groups including multi-joint or compound exercises (eg, leg press). 25 Resistance exercises were progressed based on rating of mRPE increasing the load and/or repetitions when an exercise was rated <4/10 on mRPE. At the initial sessions, the patient participated in upper and lower extremity exercises in sitting and standing with 3 lb dumbbells or ankle weights. Exercises progressed slowly to include functional movements including squats and lunges as well increased resistance progressing to 6lb weights by the seventh session. The patient did not engage in strength training after session twelve as the physical therapist provided education for patients to perform independently at home, thus, promoting selfefficacy.

Breathing techniques focused on controlled diaphragmatic breathing with cues for relaxation and mindfulness to reduce anxiety and improve overall mood. 26 The patient completed these exercises at four supervised sessions with education to complete at home on daily basis. Diaphragmatic breathing techniques were combined with general core and trunk exercises in sitting, quadruped, or standing. One example prolonged expiration with seated trunk flexion and slow inspiration with trunk extension. Similar concepts were utilized with patient performing controlled breathing activities during core exercises in the quadruped position for lumbar extension and flexion with core activation eg, cat-cow exercise, child's pose, and bird-dog exercises.

The goal of these techniques was not to improve core stability, but rather to increase chest wall expansion with increased attention to diaphragmatic breathing while engaging core musculature. Core stability is purported to be a vital component of efficient respiratory muscle activation 27 with previous findings demonstrating that core stabilization exercises with breathing are more effective in improving pulmonary function. 28 

training with an elastic resistance band at home completing 3 sets of 15 repetitions at least 3 times per week (Fig. 2) . The patient was also educated to perform diaphragmatic breathing each day as well as at any time the patient experienced anxiety or distress. She gradually increased time participating in exercises and activities at home, which peaked at week 6 and reduced in weeks 7 and 8, Figure 2 . In addition, the patient reported return to participation in yard-work including potting plants and mowing during week 3 and aerobic training on her stationary bicycle. She was able to return to swimming for aerobic training at week 7. 

Following physical rehabilitation, the patient participated in outcome testing 120 days after initial diagnosis;

findings are summarized in the 

distress, intrusion, avoidance, and hyperarousal). On day 153, the patient was referred to neurology and imaging of the head was performed for ongoing symptoms including daily migraines, left-sided tingling and cognitive fog. Magnetic resonance imaging revealed mild amount of scattered small T2 hyperintense foci in the bilateral cerebral white matter and subcortical distribution, nonspecific in nature, similar to patients with migraines. At the time of this report, the patient continues to have daily migraines, fatigue and dyspnea that are worse with exertion, cognitive deficits, and left-sided parasthesias. The continued presence of symptoms four months after initial diagnosis led to continue medical follow-up with patient being referred for cognitive rehabilitation led by an occupational therapist.

The findings in this case report demonstrate that individuals diagnosed with COVID-19 who never require hospitalization may still be at risk of impairments in physical function, cognition and emotional health.

The patient described in this case report continues to have debilitating symptoms 6-months after mild COVID-19 disease. We present this case report to highlight the severity of symptoms and demonstrate the arduous recovery some patients are facing despite never requiring an admission to the hospital. Moreover, we emphasize the need for ongoing physical and cognitive rehabilitation to address deficits developed as a result of COVID-19. In particular, we suggest that physical therapy treatment may improve post-viral symptoms of deconditioning and weakness, and potentially interventions such as diaphragmatic breathing, dancing, and mindfulness training may stimulate mood, reduce anxiety and support recovery. Eight-weeks of physical rehabilitation was associated with increased physical function and exercise capacity. However, six-minute walk test remained below her age-predicted value. Moreover, the patient's emotional health and quality of life scores did not improve following physical rehabilitation treatment likely due to post-viral syndrome referred to as post-COVID syndrome that continues to plague the patient.

The intractable symptoms experienced by the patient in this case are consistent with prior reports outlining "debilitating persistent symptoms." 3 The presence of daily symptoms months after the patient's initial positive test with subsequent negative test for SARS-CoV-2 may explain continued poor scores on distress and HrQOL questionnaires. For reference, the patient's scores on the distress questionnaire (IES-R) are similar to patient surviving critical illness due to acute respiratory failure. 30 Recent research demonstrates that the COVID-19 pandemic can have "direct neuropsychiatric consequences and indirect effects on mental

health." 31 Physiologically, coronavirus is purported to lead to cerebral and brainstem dysregulation and, or tissue damage 32 , potentially due to invasion of SARS CoV-2 through the olfactory system or the bloodstream, or indirectly by systemic proinflammatory response increasing risk of neurologic involvement. 33 The patient in this case would meet criteria for a provisional diagnosis of post-traumatic stress disorder (>33/88 on IES-R). 16 Additionally, the patient experienced debilitating daily migraines which have continued to time of this report.

Headaches are a commonly reported neurologic symptom in patients with COVID-19 and post-viral illnesses, with the pathophysiology thought to be related to immune or inflammatory responses. 34 Neuroimaging performed six-months after initial exposure revealed nonspecific changes thought to be consistent with migraines. The frequency and severity of the patient's migraines in combination with ongoing distress continued to affect her normal life routines.

The primary purpose of this case report was to present of physical therapy management for a non- community-acquired pneumonia. 37 However, the patient in this case report did not have improved scores on IES-R and HRQoL even despite a focus on reducing anxiety. We may speculate that current state of the

pandemic with large periods of isolation and restrictions may also contributed to lower scores. 38 The patient exhibited minor improvements in cognition evident in small improvements on the MOCA as well as the TUGcog. Scores on TUG and TUGcog were similar to "non-fallers" in studies previously assessing performance in older adults. 14 The difference between TUG and TUGcog scores is quantified as the "cognitive cost" with the patient having a deficit of 34% on initial examination that improved to deficit of 21%. Improvements are noted, but the deficits also suggest the patient has continued difficulty with dual-task performance, although references values are not available for TUG-cog in her age group. Therefore, we suggest physical therapy treatment may be important to address deficits in muscle strength and cardiorespiratory endurance in patients with post-COVID syndromes, but additional research is required to study effectiveness including optimal delivery.

The rehabilitation program was prescribed based on patients surviving acute respiratory failure and patients that are deconditioned. 20, 21 The initial intensities, therefore, may be considered conservative especially the low-intensity aerobic training. This was intentional due to the purported risk of cardiac and neurologic complications with COVID-19 as well as the relative unknown about the impairments with post-COVID syndromes. The optimal timing and duration of treatment are pertinent clinical questions. It is possible that starting earlier in the course of her illness may have impacted outcomes, but the referral was provided nearly 2 months after her symptom onset. It is also possible that the duration was suboptimal and she may have benefitted from more sessions. However, she was self-sufficient with her home exercise plan and it was mutually decided to discontinue supervised sessions with the option to return to clinic, if needed. The decision to stop in-person sessions was supported by the patient's high healthcare literacy and that she was actively seeking treatment for emotional and cognitive impairments. Moreover, the patient returned to cycling and swimming in the later weeks of her treatment program reaching one of her initial goals. The case report highlights the need to provide individualized physical therapy treatment to address patient specific impairments with attention to patient specific goals.

This case report highlights that younger individuals with no pre-existing health issues that have recovered from an initial SARS-COV-2 infection may be at risk for long-term impairments, referred to as post-

physiological response to exercise and the implications of post-exertional malaise and fatigue as well as emotional and cognitive function in their management of patients with post-COVID syndromes.

Health (UL1TR001998). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH.

The funders played no role in the design, conduct, or reporting of this study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest. The patient completed a walking program (orange) and home exercise plan (HEP, blue). The HEP was structured from resistance training exercises and breathing techniques performed in the clinic. The general focus included exercises involving major muscle groups such as standing hip exercises (4-way exercises) and standing upper extremity exercises (mid-rows and overhead shoulder press) with resistance band, as well as functional movements (squats, lunges, and repetitive sit-to-stand training). In addition, the patient was informed to gradually increase participation in instrumental activities of daily living and leisure activities at mild to moderate intensities. The patient reported participating in laundry, light-cleaning and grooming her dog early in her program that progressed to gardening, mowing, and cycling in weeks 4-6 and swimming in weeks 7 and 8. Time participating in activities gradually increased except in weeks 5 and 7 which may associate with increases reports of malaise, headaches, and fatigue due to over-exertion in the prior weeks.

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