Recommendations for Hospital-Based Physical Therapists Managing Patients With COVID-19

Abstract 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. 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 intensive care unit, 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.

Download Full-text

Interrater Reliability of Muscle Ultrasonography Image Acquisition by Physical Therapists in Patients Who Have or Who Survived Critical Illness

Physical Therapy ◽

10.1093/ptj/pzaa068 ◽

2020 ◽

Vol 100 (9) ◽

pp. 1701-1711 ◽

Cited By ~ 1

Author(s):

Kirby P Mayer ◽

Sanjay Dhar ◽

Evan Cassity ◽

Aaron Denham ◽

Johnny England ◽

...

Keyword(s):

Skeletal Muscle ◽

Intensive Care Unit ◽

Intensive Care ◽

Correlation Coefficient ◽

Intraclass Correlation Coefficient ◽

Interrater Reliability ◽

Physical Therapists ◽

Physical Therapist ◽

Image Acquisition ◽

Intraclass Correlation

Abstract Objective Previous studies have demonstrated that muscle ultrasound (US) can be reliably performed at the patient bedside by novice assessors with minimal training. The primary objective of this study was to determine the interrater reliability of muscle US image acquisition by physical therapists and physical therapist students. Secondarily, this study was designed to elucidate the process for training physical therapists to perform peripheral skeletal muscle US. Methods This was a cross-sectional observational study. Four novices and 1 expert participated in the study. Novice sonographers engaged in a structured training program prior to implementation. US images were obtained on the biceps brachii, quadriceps femoris, and tibialis anterior muscles in 3 groups: patients in the intensive care unit, patients on the hospital ward, and participants in the outpatient gym who were healthy. Reliability of image acquisition was analyzed compared with the expert sonographer. Results Intraclass correlation coefficient values ranged from 0.76 to 0.97 with an average for all raters and all muscles of 0.903, indicating excellent reliability of image acquisition. In general, the experienced physical therapist had higher or similar intraclass correlation coefficient values compared with the physical therapist students in relation to the expert sonographer. Conclusions Excellent interrater reliability for US was observed regardless of the level of experience, severity of patient illness, or patient setting. These findings indicate that the use of muscle US by physical therapists can accurately capture reliable images in patients with a range of illness severity and different clinical practice settings across the continuum of care. Impact Physical therapists can utilize US to obtain images to assess muscle morphology. Lay Summary Physical therapists can use noninvasive US as an imaging tool to assess the size and quality of peripheral skeletal muscle. This study demonstrates that physical therapists can receive training to reliably obtain muscle images in patients admitted to the intensive care unit who may be at risk for muscle wasting and may benefit from early rehabilitation.

Download Full-text

Physical Therapist Practice in the Intensive Care Unit: Results of a National Survey

Physical Therapy ◽

10.2522/ptj.20140417 ◽

2015 ◽

Vol 95 (10) ◽

pp. 1335-1344 ◽

Cited By ~ 30

Author(s):

Daniel Malone ◽

Kyle Ridgeway ◽

Amy Nordon-Craft ◽

Parker Moss ◽

Margaret Schenkman ◽

...

Keyword(s):

United States ◽

Intensive Care Unit ◽

Intensive Care ◽

Physical Therapy ◽

Acute Care ◽

National Survey ◽

Physical Therapists ◽

Physical Therapist ◽

Community Hospitals ◽

American Physical

Background Early rehabilitation improves outcomes, and increased use of physical therapist services in the intensive care unit (ICU) has been recommended. Little is known about the implementation of early rehabilitation programs or physical therapists' preparation and perceptions of care in the United States. Objective A national survey was conducted to determine the current status of physical therapist practice in the ICU. Design This study used a cross-sectional, observational design. Methods Self-report surveys were mailed to members of the Acute Care Section of the American Physical Therapy Association. Questions addressed staffing, training, barriers, and protocols, and case scenarios were used to determine perceptions about providing rehabilitation. Results The response rate was 29% (667/2,320). Staffing, defined as the number of physical therapists per 100 ICU beds, was highest in community hospitals (academic: median=5.4 [range=3.6–9.2]; community: median=6.7 [range=4.4–10.0]) and in the western United States (median=7.5 [range=4.2–12.9]). Twelve percent of physical therapists reported no training. Barriers to providing ICU rehabilitation included insufficient staffing and training, departmental prioritization policies, and inadequate consultation criteria. Responses to case scenarios demonstrated differences in the likelihood of consultation and physical therapists' prescribed frequency and intensity of care based on medical interventions rather than characteristics of patients. Physical therapists in academic hospitals were more likely to be involved in the care of patients in each scenario and were more likely to perform higher-intensity mobilization. Limitations Members of the Acute Care Section of the American Physical Therapy Association may not represent most practicing physical therapists, and the 29% return rate may have contributed to response bias. Conclusions Although staffing was higher in community hospitals, therapists in academic and community hospitals cited insufficient staffing as the most common barrier to providing rehabilitation in the ICU. Implementing strategies to overcome barriers identified in this study may improve the delivery of ICU rehabilitation services.

Download Full-text

Physical Therapist Management of COVID-19 in the Intensive Care Unit: The West China Hospital Experience

Physical Therapy ◽

10.1093/ptj/pzaa198 ◽

2020 ◽

Author(s):

Lei Li ◽

Pengming Yu ◽

Mengxuan Yang ◽

Wei Xie ◽

Liyi Huang ◽

...

Keyword(s):

Public Health ◽

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Physical Therapists ◽

Physical Therapist ◽

Maximal Inspiratory Pressure ◽

Mobility Index ◽

The Public ◽

Clinical Center

Abstract Objective Coronavirus disease 2019 (COVID-19) has dominated the attention of health care systems globally since January 2020. Various health disciplines including physical therapists are still exploring the best way to manage this new disease. The role and involvement of physical therapists in the management of COVID-19 are not yet well defined and are limited in many hospitals. This article reports a physical therapy service specially commissioned by the Health Commission of Sichuan Province to manage COVID-19 during patients’ stay in the intensive care unit (ICU) at the Public Health Clinical Center of Chengdu in China. Methods Patients diagnosed with COVID-19 were classified into 4 categories under a directive from the National Health Commission of the People’s Republic of China. Patients in the “severe” and “critical” categories were admitted to the ICU irrespective whether mechanical ventilation was required. Between January 31, 2020, and March 8, 2020, a cohort of 16 patients was admitted to the ICU at the Public Health Clinical Center of Chengdu. The median (minimum to maximum) hospital and ICU stays for these patients were 27 (11–46) and 15 (6–38) days, respectively. Medical management included antiviral, immunoregulation and supportive treatment of associated comorbidities. Physical therapist interventions included body positioning, airway clearance techniques, oscillatory positive end-expiratory pressure, inspiratory muscle training, and mobility exercises. All patients had at least 1 comorbidity. Three of the 16 patients required mechanical ventilation and were excluded for outcome measures that required understanding of verbal instructions. In the remaining 13 patients, respiratory outcomes—including the Borg Dyspnea Scale, peak expiratory flow rate, Pao2/Fio2 ratio, maximal inspiratory pressure, strength outcomes, Medical Research Council Sum Score, and functional outcomes (including the Physical Function in Intensive Care Test score, De Morton Mobility Index, and Modified Barthel Index)—were measured on the first day the patient received the physical therapist intervention and at discharge. Results At discharge from the ICU, while most outcome measures were near normal for the majority of the patients, 61% and 31% of these patients had peak expiratory flow rate and maximal inspiratory pressure below 80% of the predicted value and 46% had De Morton Mobility Index values below the normative value. Conclusion The respiratory and physical functions of some patients remained poor at ICU discharge, suggesting that long-term rehabilitation may be required for these patients. Impact Our experience in the management of patients with COVID-19 has revealed that physical therapist intervention is safe and appears to be associated with an improvement in respiratory and physical function in patients with COVID-19 in the ICU.

Download Full-text

Faculty Opinions recommendation of The incidence of low venous oxygen saturation on admission to the intensive care unit: a multi-center observational study in The Netherlands.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1131846.588934 ◽

2008 ◽

Author(s):

Martin Duenser

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

The Netherlands ◽

Observational Study ◽

Oxygen Saturation ◽

Venous Oxygen Saturation

Download Full-text

Faculty Opinions recommendation of Intensive care unit bed availability and outcomes for hospitalized patients with sudden clinical deterioration.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.718021968.793479060 ◽

2013 ◽

Author(s):

Rik Gerritsen

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Hospitalized Patients ◽

Clinical Deterioration

Download Full-text

Respiratory Modalities in Preventing Reintubation in a Pediatric Intensive Care Unit

Global Pediatric Health ◽

10.1177/2333794x21991531 ◽

2021 ◽

Vol 8 ◽

pp. 2333794X2199153

Author(s):

Ameer Al-Hadidi ◽

Morta Lapkus ◽

Patrick Karabon ◽

Begum Akay ◽

Paras Khandhar

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Pediatric Intensive Care Unit ◽

Noninvasive Positive Pressure Ventilation ◽

Pediatric Intensive Care ◽

Nasal Cannula ◽

Respiratory Support ◽

Positive Pressure ◽

P Value

Post-extubation respiratory failure requiring reintubation in a Pediatric Intensive Care Unit (PICU) results in significant morbidity. Data in the pediatric population comparing various therapeutic respiratory modalities for avoiding reintubation is lacking. Our objective was to compare therapeutic respiratory modalities following extubation from mechanical ventilation. About 491 children admitted to a single-center PICU requiring mechanical ventilation from January 2010 through December 2017 were retrospectively reviewed. Therapeutic respiratory support assisted in avoiding reintubation in the majority of patients initially extubated to room air or nasal cannula with high-flow nasal cannula (80%) or noninvasive positive pressure ventilation (100%). Patients requiring therapeutic respiratory support had longer PICU LOS (10.92 vs 6.91 days, P-value = .0357) and hospital LOS (16.43 vs 10.20 days, P-value = .0250). Therapeutic respiratory support following extubation can assist in avoiding reintubation. Those who required therapeutic respiratory support experienced a significantly longer PICU and hospital LOS. Further prospective clinical trials are warranted.

Download Full-text