physiotherapy after COVID-19

  physiotherapy after COVID-19                                (continue)

7. Clinical outcome measures for the first six weeks

 It is important to identify factors that can influence recovery and/or can guide clinical decision making. The WHO-ICF can serve as a model to capture and organize several constructs from subjective and objective assessment. Clinical outcome measures are used to assess and evaluate the functioning of patients, guide clinical decision making and optimize treatment. The core set of clinical outcome measures for the first six weeks after hospital discharge or illness from COVID-19 at home consists of: 

• Patient Specific Functioning Scale (PSFS) to determine the perceived physical limitations in participation and activities of daily living.

 • Borg Scale CR10 for Shortness of Breath and Fatigue indicating shortness of breath and fatigue experienced by the patient. A maximum threshold score for exercise intensity of 4 out of 10 on the Borg Scale CR10 applies at this time after illness. 

• Oxygen saturation (SpO2 ) at rest, during and after physical activity and therapeutic exercise. If the physiotherapist has a pulse oximeter, it can be delivered to the patient’s home, when treatment is provided remotely.

 • Heart rate (HR) at rest, during and after physical activity and therapeutic exercise. In case of ehealth consultation, heart rate can be measured by instructing the patient on how to measure it himself, for example using the Version 2.0 / 27 July 2020 15 KNGF position statement: Recommendations for physiotherapy in patients with COVID-19 pulse oximeter or by instructing the patient how to measure it themselves with the heart rate indicated by the patient (‘counting strokes aloud’). The physiotherapist should be aware that outcomes can be influenced by medication.

 • Short Physical Performance Battery (SPPB) to measure balance, muscle strength and mobility. The SPPB consists of a balance test, walking speed over 4 meters and 5 times repeated standing up from a chair test. The physiotherapist must at all times ensure the safety of the patient if they are (seriously) weakened. In case of e-health consultation, the SPPB cannot be performed.

 • Grip Strength to estimate overall peripheral muscle strength. If possible and available, a hand-held dynamometer is used.

 • 6-Minute Walk Test (6MWT) to estimate the exercise capacity. In case of e-health consultation or the patient has (very) low exercise tolerance levels, the 6MWT should not be attempted. 

 • Short Nutritional Assessment Questionnaire (SNAQ65+) for early detection of malnutrition in patients who have been hospitalized. The physiotherapist uses the SNAQ65+ to identify a potential malnutrition status of the patient. A dietician should be consulted or referred to in case of signs of malnutrition. It is important that the physiotherapist and dietician have good communication and collaboration.

 In this position statement, the clinical outcome measures focus on physical functioning. Optionally, during the first six weeks, a pedometer/accelerometer can be used to determine and monitor daily physical activity levels. Also, one-repetition maximum (1RM) tests can be used to determine muscle strength of specific muscle groups and to determine initial intensities of exercises which improve muscle strength .

 Besides physiotherapy specific assessment and treatment, the physiotherapist plays an important role in identifying factors that may limit (the speed of) recovery, in particular in case the patient is not also monitored by the GP or hospital. Factors to be aware of include nutritional status, cognitive and emotional functioning and psychosocial functioning. 

A multidisciplinary approach may be necessary when such factors are present. The decision on specific clinical outcome measures also depends on collaboration with other healthcare disciplines. Use of different clinical outcomes for the same constructs by different healthcare professionals should be avoided to facilitate interdisciplinary communication and monitoring of the patient, and not burden the patient unnecessarily.

 10 Core set of clinical outcome measures ‘first six weeks’ 

• Use the Patient Specific Functioning Scale to identify perceived limitations in activities of daily living. 

• Use the Borg Scale CR10 to monitor shortness of breath and fatigue.

 • Before, during and after physical activity and exercises, monitor the patient’s oxygen saturation and heart rate.

 • Use the Short Physical Performance Battery (SPPB) to measure balance, muscle strength and mobility. 

• Use grip strength measurements (hand held dynamometer) to estimate overall peripheral muscle strength.

 • Use, when safe, 6-minutes walk test (6MWT) to estimate the exercise capacity.

 • Use the Short Nutritional Assessment Questionnaire (SNAQ65+) for early identification of potential malnutrition in patients who have been hospitalized. 

8. Advice and coaching

 It is important to provide information and educate the patient about the disease process, the expected course of recovery and physiotherapy treatment plan. 

If physical functioning of the patient is limited, the physiotherapist advises and coaches the patient to gradually increase physical functioning. For example, postural advice to promote breathing and to reduce tightness, mobilizing exercises aimed at activities of daily living, and exercise to improve strength of large muscle groups. In patients with (very) low exercise tolerance, for example those with PICS, resuming daily activities in the home environment should be gradual and well monitored. Activities of daily living and supporting therapeutic exercises should be performed at low to moderate intensity and be of limited duration at this stage. See further recommendations for exercise prescription below. 

                                   Advice and coaching 

• Provide information and educate the patient about the disease process, the expected course of recovery and physiotherapy treatment plan

 • Advise and coach the patient to gradually increase activities of daily living and physical activity, such as therapeutic exercises. Monitor the patient’s levels of daily functioning. 

•In patients with (very) low exercise tolerance, activities of daily living and additional exercise therapy should be performed at low to moderate intensity and be of short duration (see further recommendations for exercise prescription below).

 Exercise prescription Specific parameters for exercise prescription depend on activity levels of the patient prior to the COVID-19 infection, the patient’s needs and current physical abilities of the patient. In the first six weeks, the emphasis is on returning to activities of daily living. A maximum score of 4 out of 10 on the Borg Scale CR10 for Shortness of Breath and Fatigue is recommended. Reasons for this recommendation are:

    • COVID-19 can severely impact lung function (including oxygen desaturation during exercise due to virus-induced and/or pre-existing lung disease). 

  • COVID-19 can severely affect cardiac function (including virus-induced myocarditis, arrhythmia and/or pre-existing cardiac disease).

   • After the active COVID-19 infection, no maximal exercise testing is done, partly due to organizational limitations in hospitals due to the corona crisis.