Rehabilitation after COVID-19

WORLD PHYSIOTHERAPY DAY” Sept 8, 2020

Dr.Basavaraj S. Nanjannavar M.P.T.

Physiotherapy or physical therapy is a treatment methodology majorly sought for acute or chronic pain of musculoskeletal origin. It also involves treating movement dysfunction or physical impairment resulting from injury or illness of musculoskeletal, neurological, cardiovascular and respiratory or of endocrinological origins.

The first world war and the epidemic of Polio, a hundred years ago, marked the start of the profession which grew in dominance during the second world war as the world required the attention of physiotherapists for wounded soldiers who returned home with amputations, burns, cold injuries, wounds, fractures, and nerve and spinal cord injuries. The later years of the 1960s and ’70s saw the expansion of the profession and have continued to grow substantially further in the 20th century with a lot of evidence for treatment utility based on research being added to the field. So, physiotherapy is just not a method but science that has grounded strongly through a lot of quality research conducted worldwide and whose evaluation and treatment are all based on the evidence found through this quality researches. In India, the foundation for physiotherapy was laid in 1952 at Bombay following an epidemic of poliomyelitis. Later, in 1962 the Indian Association of Physiotherapists (IAP) was formed which has played a crucial part in the development of physiotherapy as a profession. Although the field continues to grow scientifically, awareness of physiotherapy among the community and other medical professionals is eluded.

The International Standard Classification of Occupations (ISCO) Code 2264 of the World Health Organization (WHO) defines physiotherapy as “Physiotherapists assess, plan and implement rehabilitative programs that improve or restore human motor functions, maximize movement ability, relieve pain syndromes, and treat or prevent physical challenges associated with injuries, diseases, and other impairments. They apply a broad range of physical therapies and techniques such as movement, ultrasound, heating, laser, and other techniques. They may develop and implement programs for screening and prevention of common physical ailments and disorders”. As such, physiotherapy addresses the illnesses or injuries that limit a person’s ability to move and perform functional activities in their daily lives. Physiotherapists provide services that develop, maintain and restore people’s movement and functional ability to their maximum. They help people to improve on the quality of life whose body functions are threatened by aging, injury, diseases, disorders etc. They work in association with other health professionals to promote health, treat and prevent a condition and rehabilitate. They use an individual’s history and physical examination to arrive at a diagnosis and establish a management plan and, when necessary, incorporate the results of laboratory and imaging studies like X-rays, CT-scan, or MRI findings.  Physiotherapy management commonly includes specific exercises, manual therapy, mechanical devices such as traction, electrophysical modalities such as heat, cold, electricity, sound waves & radiation, assistive devices such as prostheses & orthoses, and other interventions like pain education. In addition, physiotherapists work with individuals to prevent injuries and loss of mobility before it occurs by developing fitness programs specifically for that condition and occupation

In Short, Physiotherapists:

  • undertake a comprehensive examination/assessment of the patient
  • evaluate the findings from the examination/assessment to make clinical judgments
  • formulate a diagnosis, prognosis and plan
  • provide consultation within their expertise
  • implement a physiotherapy intervention/treatment program
  • determine the outcomes of any interventions/treatments
  • make recommendations for self-management

World Physiotherapy, a global body of 122 member organizations of which IAP from India is also a part, is committed to furthering the physiotherapy profession and improving global health. It supports the development of high-quality physiotherapy education by publishing entry-level curriculum guidelines, policies, and a range of resources and opportunities. It was founded on September 8th, 1951 and presently it represents more than 670,000 physiotherapists worldwide. In 1996, 8 September was designated as World PT Day. The day marks the unity and solidarity of the global physiotherapy community and is an opportunity to recognize the work that physiotherapists do for their patients and community. On this day lot of community, programs are undertaken to create an awareness of physiotherapy. The theme for 2020 World PT Day is “Rehabilitation after COVID-19”, and it seems to be very apt for the present state under which the world is reeling. I take this opportunity to explain the benefits of physiotherapy which can be helpful for the whole community during the present COVID crisis.

Coronavirus Disease 2019 ( COVID-19) caused by Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS-CoV-2), is a single-stranded ribonucleic acid (RNA) encapsulated coronavirus and is highly contagious. Transmission is predominantly by droplet spread (i.e. relatively large particles that settle in the air), and direct contact with the patient. There is still no specific antiviral treatment for COVID-19 infection, only supportive therapies including respiratory care for affected patients, especially in more severe cases. To date, COVID-19 patients who require hospitalization are presenting with pneumonia features and bilateral patchy shadows or ground-glass opacity in the lungs. Most people with COVID-19 have no symptoms or only end up with a mild illness.  Small limited populations who end up in hospitals are in respiratory distress and require mechanical ventilation. The respiratory compromise caused by COVID-19 should not be burdened more by causing respiratory distress and thus various physiotherapeutic respiratory techniques are avoided during the acute phase. However, to mitigate the effects of prolonged bed rest and mechanical ventilation, the patient should be encouraged to perform active movements. That means doing exercises, as well as sitting up and walking around can be beneficial for early discharge. But a further key element in improving a patient’s lung function. There have been no reports of COVID-19 positive patients having high secretion loads that would require intensive respiratory physiotherapy/airway clearance. However, during the recovery stages of the disease, the patient can use the ACBT techniques and lung volume recruitment procedures to improve the lung functions and thus the oxygenation. I will be discussing the ACBT technique here and urge all to perform it in an isolated setup.

The ACBT is an active breathing technique performed by the patient and can be used to mobilize and clear excess lung secretions and generally helps improve lung function. ACBT can be performed in sitting or in a side-lying or prone lying position. Duration for ACBT should be for about 10 minutes or until your chest feels clear of sputum. ACBT can be performed once or twice a day. When you have more sputum, you may need to do it more often but for a shorter duration of time. If you are unable to follow the instructions then please do not perform the exercise.

ACBT consists of three main phases:

  1. Breathing Control
  2. Deep Breathing Exercises or Thoracic Expansion Exercises
  3. Huffing

Breathing Control:

Breathe in and out gently through your nose. (At your own rate)

Let go of any tension in your body with each breath and keep your shoulders relaxed.

Gradually try to make the breaths full but slower.

Try closing your eyes to help you to focus on your breathing and to relax.

Gain control of breathing in this manner.

Thoracic Expansion Exercises

Try to keep your chest and shoulders relaxed.

Take a long, slow and deep breath in, through your nose.

At the end of breath in, hold the air in your lungs for 2-3 seconds before breathing out

Breathe out gently and relaxed, like a sigh. Don’t force the air out.

Repeat 3 – 5 times.

Huffing:

This is a technique that helps move secretions, loosened by thoracic expansion exercises, towards the mouth. A huff is breathing out through an open mouth and throat instead of coughing. Huffing helps moves sputum from the small airways to the larger airways, from where they are removed by coughing. There are two types of huff: A medium-volume huff and a large volume huff.

Medium Volume Huff:

This helps to move secretions that are lower down in your airways.

Method: Take a normal-sized breath in and then an active, long breath out until your lungs feel quite empty. Imagine you are trying to steam up a mirror.

High Volume Huff:

This helps to move secretions in your upper airways.

Method: Take a deep breath in, open your mouth wide and huff out quickly. Only perform 1-2 huffs together, as repeatedly huffing can make your chest tight.

Listen for crackles when you huff, If you can hear these, you may now need to cough and clear secretions; try to spit them out into a tissue or a sputum bowl. Try to avoid excessive coughing as it may be excessively tiring.

Repeat the whole cycle for about 10 minutes or until the chest feels clearer.

Persistent fatigue, breathlessness, and ongoing pain are recognized as some of the key challenges for the ‘COVID-19 long haulers i.e. those who have ongoing symptoms long after the initial positive test. Currently, there is no standard dedicated rehabilitation pathway for patients after they leave hospital. One can continue to do breathing exercises and keep themselves as active as possible. Exercises have been proved to reduce stress and depression and improve self-confidence and also improve sleep quality and duration. They help to improve the strength of muscles and also the cardiorespiratory function. Initially, till 6 weeks, the activities in daily life and additional exercises should be performed at low to moderate intensity, with a short duration of exertion so that there is no shortness of breath and fatigue. However as the world negotiates the potential long-term effects of COVID-19, after 6 weeks one can keep themselves active and do the exercises to their capacity while keeping a close watch on the shortness of breath and fatigue.

In the end I wish you all a safe and healthy journey and wish you all a very HAPPY WORLD PHYSIOTHERAPY DAY.

About the Author:

Dr.Basavaraj S. Nanjannavar M.P.T. Asst. Professor, Department of Physiotherapy, BIMS,   Consulting Physiotherapist, Deesha Healthcare Belagavi

LEAVE A REPLY

Please enter your comment!
Please enter your name here