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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 114-118

A journey to recovery with a tailor-made physiotherapy intervention in an acute care setup of COVID-19 management: A case study


Physiotherapy School and Centre, TNMC and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India

Date of Submission05-Oct-2020
Date of Decision30-Nov-2020
Date of Acceptance11-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Chhaya Vijaykumar Verma
Physiotherapy School and Centre, TNMC and BYL Nair Charitable Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_50_20

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  Abstract 


Coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to lower psychological well-being and high levels of anxiety in general public. SARS-CoV-2 causes acute respiratory distress syndrome, which can lead to breathlessness requiring mechanical ventilation and Intensive care management. Physiotherapy plays a crucial role in the management of intubated as well as nonintubated patients admitted in the ICU, thereby helping the patients progress in their recovery. This case study highlights the importance of a Tailor-made Physiotherapy Intervention in improving the quality of life of a 48-year-old male, with a history of Diabetes Mellitus and Moderate Alcohol intake who presented in our dedicated COVID Government Tertiary Care Hospital with complaints of fever, breathlessness on walking, and fatigue. After the evaluation by the Physiotherapist on the basis of International Classification of Functioning Model, the patient was educated about the condition, and a Physiotherapy Intervention plan was formulated with emphasis on Pulmonary Rehabilitation considering the health status and vital parameters of the patient. From our experience, we conclude that a Tailor-made Physiotherapy Intervention in hand with medical management is essential to restore function and improve the quality of life of patients with COVID-19.

Keywords: Coronavirus Disease 19, patient education, physiotherapy intervention, rehabilitation, severe acute respiratory syndrome coronavirus 2


How to cite this article:
Mangaonkar AN, Savla NP, Verma CV, Kubal SV. A journey to recovery with a tailor-made physiotherapy intervention in an acute care setup of COVID-19 management: A case study. Physiother - J Indian Assoc Physiother 2020;14:114-8

How to cite this URL:
Mangaonkar AN, Savla NP, Verma CV, Kubal SV. A journey to recovery with a tailor-made physiotherapy intervention in an acute care setup of COVID-19 management: A case study. Physiother - J Indian Assoc Physiother [serial online] 2020 [cited 2021 Jul 28];14:114-8. Available from: https://www.pjiap.org/text.asp?2020/14/2/114/305844




  Introduction Top


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel virus, first identified in Wuhan causes a highly contagious disease called the Coronavirus Disease (COVID-19) with a mortality rate of 3%–4% which has surged to 9% with time.[1]

A higher prevalence of COVID-19 is observed in patients with comorbidities, mainly hypertension (17%) and diabetes (8%), with 72% requiring intensive care management.[2] Furthermore, people with a history of alcohol intake are at a greater risk of worse COVID-19 outcome owing to the dysfunctional immune system and increased presentation of ACE receptors in the respiratory tract.[3]

Physiotherapy plays a vital role in the management of patients with respiratory conditions providing therapeutic interventions to prevent complications, restore function, and make the patient functionally independent in his activities of daily living.[4]

The purpose of this case report is to highlight the role of a Tailor-made Physiotherapy Intervention in the management of a middle-aged man with COVID-19 giving a history of dDiabetes Mellitus and Moderate Alcohol intake in an Acute Care Set up.


  Case Report Top


Patient presentation

A 48-year-old male, Government employee and an Amateur Singer, with a history of Diabetes Mellitus and Moderate Alcohol intake, presented in our dedicated COVID Government Tertiary Care Hospital with Fever since 5 days, breathlessness on walking and fatigue since 2 days. He gave a history of contact with a COVID-positive patient at his workplace, after which he developed symptoms and was tested positive for COVID on Reverse Transcriptase Polymerase Chain Reaction (RT PCR) test. On the basis of X-ray and High resolution Computed Tomography findings, the patient was diagnosed as COVID-19 with pneumonia and severe acute respiratory distress syndrome. He was initially admitted in the COVID wards with an external oxygen support of 10 l/min through bag and mask ventilation. In the next few days, as his complaints of breathlessness aggravated, he was shifted to semi-intensive care unit (ICU) and was put on BIPAP with a FiO2 of 100%. In this course, the medical management of the patient comprised of Broad spectrum antibiotics, Corticosteroids, Immunosuppressant , Anticoagulants and Injection Insulin for Diabetes.

After ensuring stability in the vitals and health condition of the patient, Physiotherapy referral was given on the 12th day of admission by the treating physician. At that time, the patient was on BIPAP support with FiO2 of 100% in the semi-ICU. Physiotherapy evaluation was performed according to the International Classification of Functioning Approach( Biopsychosocial Model) as given in [Table 1].[5]
Table 1: International classification of functioning evaluation on referral by treating physician Day 1 of Physiotherapy management i.e Day 12 post admission

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Intervention

  1. Physiotherapy management comprising of chest physiotherapy and mobilization protocol as seen in [Figure 1]a was planned in accordance with the Physiotherapy Guidelines published by our tertiary care hospital[6]
  2. Mobilization was progressed steadily in a sequential manner from in bed mobility to ambulation in the ward only when resting SpO2 >90%, heart rate was more than 60 beats per minute (bpm) but <120 bpm
  3. Exercise was terminated if a drop of >3% in the SpO2 was observed and the treating physician was notified.
Figure 1: (a) Tailor-made physiotherapy intervention plan (b) Day-wise physiotherapy treatment from relaxation (1) progressing to ambulation (8) with consideration of patient's symptoms and overall health condition

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Outcomes

Before discharge, Physiotherapy re-evaluation was performed as seen in [Table 2].
Table 2: International classification of functioning evaluation before discharge Day 19 of Physiotherapy management i.e Day 34 post admission

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  Discussion Top


COVID-19 has presented an unprecedented challenge for health-care fraternity worldwide because of its uncertain pathophysiology and nonselective nature of affection. Diabetes leads to a worsened prognosis and increases the mortality rate in patients with COVID-19 owing to the reduced viral clearance observed as a result of a defect in the T-cell and complement action.[7] Similarly, it has been proposed by the WHO that alcohol intake reduces the ability to cope with infectious disease by weakening the immune system, leading to serious complications of COVID-19.[8]

This case report highlights the variation in the health condition of a middle-aged man with COVID-19 with a history of Diabetes Mellitus and Moderate Alcohol Intake and how pulmonary rehabilitation initiated as a part of Physiotherapy Intervention helped in improving his health status and made him functionally independent by being an integral part of the multidisciplinary team.

Rehabilitation was started by targeting the psychological aspect of the patient's health as breathing and emotions share a physiological basis owing to the autonomic nervous system. This interlinked relationship between the physiological and psychological aspects of health made it essential to integrate music along with breathing strategies to induce relaxation and relieve anxiety, apprehension, and dyspnea.[9]

Considering the ventilation/perfusion mismatch as one of the pathophysiology of COVID-19, positioning strategies were initiated according to the CARP protocol emphasizing on left lateral recumbent and upright sitting position with a goal of improving ventilation, thereby optimizing oxygenation, reducing work of breathing and pressure time product of respiratory muscles.[10] Lateral thoracic expansion along with lateral stretches was given in conjunction with positioning strategies in an attempt to increase lung volume, mobilize the thoracic cage, and increase the efficiency of respiratory muscles.[11]

Studies have shown that early mobilization in bed, at the bedside or in standing reduces the incidence of ICU-acquired weakness, facilitates early weaning, and increases discharge-to-home rate.[12] For this patient, physiotherapy management in consensus with the treating physician was steadily progressed from bedside sitting to standing with a FiO2 of 95% along with careful monitoring of patient's symptoms and SpO2 levels. Adequate rest pauses were given between exercises to avoid excessive fatigue and desaturation.

Soon after, spot marching (5 steps) was started with careful consideration of patient's health condition. Following a drop in SpO2 values >3%, spot marching was discontinued and the patient was positioned in dyspnea relieving position (e.g., semi-Fowler's) and advised relaxed breathing to prevent further drop and deterioration in patient condition.

When the patient was shifted from BIPAP to 15 l/min of O2 support with bag and mask ventilation, his symptoms of breathlessness aggravated with a drop in SpO2 levels due to which physiotherapy management had to be titrated down to positioning and in bed mobility with relaxed breathing as shown in [Figure 1]b. Thereafter, as a result of Medical, Nutritional, Psychological and Physiotherapeutic management, a steady progression was observed in the health condition of the patient.

Ambulation around the patient's bed was started with O2 supply of 2 l/min through nasal cannula and SpO2 monitoring following considerable improvement in his health after he was shifted to COVID wards. After the patient was weaned off the O2 support in a few days, an increment in the ambulation distance was carried out under strict supervision of physiotherapist and treating physician. [Figure 2] and [Figure 3] show the day-wise immediate changes in the oxygen saturation and heart rate, respectively, following physiotherapeutic interventions.
Figure 2: Day-wise immediate change in oxygen saturation following physiotherapeutic intervention

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Figure 3: Day-wise immediate change in heart rate following physiotherapeutic intervention

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Only after the patient was asymptomatic, negative on RT PCR, and was able to maintain oxygen saturation without any external oxygen support he was planned for the discharge program. The patient has been advised a physiotherapy home protocol with emphasis on positioning, controlled relaxed breathing, and mobility exercises. A regular follow-up is being taken with guided, supervised monitoring of the patient through telecommunication.

Overall in our experience, Physiotherapy Intervention tailored as per the patient needs along with the medical management led to a good quality of life for the patient with COVID-19.

Patient perspective (in his own verbatim)

The time I was admitted, I was very scared. I didn't know if I would survive this and get back home safely. I was very anxious since I had tested positive for COVID-19 and was experiencing shortness of breath. My condition was critical. Seeing three deaths on the 1st day itself did not make this journey easy for me. However, with the support and care of the entire hospital staff, doctors, nurses, and physical therapist, I could defeat COVID-19. My heartfelt gratitude goes toward all the health-care workers. Currently, I am home quarantined and continuing the exercises prescribed to me regularly.

Acknowledgements

The authors acknowledge Dr Seema Kini (Associate Professor, Department of Medicine, T.N.M.C & B.Y.L Nair Hospital), Dr. Mohan Joshi (Dean T.N.M.C & B.Y.L Nair Hospital) for encouraging us to carry out this study, our Patient who co operated and gave us the consent to use the information, Dr Konrad Dias, Associate Professor of Physical Therapy , Maryville University and a Cardiopulmonary Physical Expert for his valuable contribution in shaping this case report, All Postgraduate Students , Faculty and Staff Members of Physiotherapy School and centre , T.N.M.C & B.Y.L Nair Hospital.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Coronavirus Disease 2019 (COVID 19) Situation Report-74. World Health Organization; 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200403-sitrep-74-covid-19-mp.pdf?sfvrsn=4e043d03_14. [Last accessed on 2020 Oct 01].  Back to cited text no. 1
    
2.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 2
    
3.
Dubey MJ, Ghosh R, Chatterjee S, Biswas P, Chatterjee S, Dubey S, et al. COVID-19 and addiction. Diabetes Metab Syndr 2020;14:817-23.  Back to cited text no. 3
    
4.
Elkins M, Jenkins S, Bradley J, Schivinski C. Chronic respiratory disease: high-quality evidence supports greater physiotherapy intervention. Physiotherapy. 2015;101:e4-e5.  Back to cited text no. 4
    
5.
World Health Organization. International Classification of Functioning, Disability, and Health. Geneva, Switzerland: World Health Organization; 2001. Available from: https://psychiatr.ru/download/1313?view=name=CF_18.pdf. [Last accessed on 2020 Oct 01].  Back to cited text no. 5
    
6.
Verma CV, Arora RD, Shetye JV, Karnik ND, Patil PC, Mistry HM, et al. Guidelines of physiotherapy management in acute care of COVID-19 at dedicated COVID center in Mumbai. Physiother – J Indian Assoc Physiother 2020;14:55.  Back to cited text no. 6
    
7.
Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practical considerations. Diabetes Metab Syndr 2020;14:303-10.  Back to cited text no. 7
    
8.
Alcohol and COVID-19: what you Need to Know. World Health Organization; 2020 (Regional office-Europe). Available from: https://www.euro.who.int/__data/assets/pdf_file/0010/437608/Alcohol-and-COVID-19-what-you-need-to-know.pdf?ua=1. [Last accessed on 2020 Oct 01].  Back to cited text no. 8
    
9.
Synn AR, Choe M. Effect of music therapy on the physiological index, anxiety and dyspnea of patients with mechanical ventilator weaning. J Korean Biol Nurs Sci 2012;14:57-65.  Back to cited text no. 9
    
10.
Mezidi M, Guérin C. Effects of patient positioning on respiratory mechanics in mechanically ventilated ICU patients. Ann Transl Med 2018;6:384.  Back to cited text no. 10
    
11.
Tucker B, Jenkins S. The effect of breathing exercises with body positioning on regional lung ventilation. Aust J Physiother 1996;42:219-27.  Back to cited text no. 11
    
12.
Zhang L, Hu W, Cai Z, Liu J, Wu J, Deng Y, et al. Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PLoS One 2019;14:e0223185.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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