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Management of COVID+ patients in Physical Medicine and Rehabilitation (MPR), and on return home

Réponses rapides dans le cadre du COVID 19 - Posted on Apr 17 2020

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Key points

  • Rapid response No. 1: Respiratory, cardiovascular, renal, neurocognitive, psychiatric, musculoskeletal, metabolic and nutritional deficiencies of variable severity, restricting activity, are common and particularly significant in these patients, requiring long-term treatment.
  • Rapid response No. 2: The risk of contamination requires strict application of protective measures during physiotherapy/rehabilitation sessions throughout the contagious phase, which can last beyond the acute phase.
  • Rapid response No. 3: The objectives of hospitalisation in a Physical Medicine and Rehabilitation unit are diagnostic evaluation and assessment of specific deficiencies and restrictions in activity, definition of physiotherapy/rehabilitation programmes and follow-up of medical complications.
  • Rapid response No. 4: Some patients require a multidisciplinary physiotherapy/rehabilitation programme coordinated by a Physical Medicine and Rehabilitation physician. The use of oxygen therapy is often necessary.
  • Rapid response No. 5: For as long as the patient’s condition is not stabilised, physiotherapy/rehabilitation must take into account the risk of cardiorespiratory decompensation and specific thromboembolic complications, with monitoring of vital signs.
  • Rapid response No. 6: Each physiotherapy/rehabilitation intervention should take into account the fatigability of these patients, who are often undernourished and asthenic and present comorbidities.
  • Rapid response No. 7: Physiotherapy/rehabilitation at home may be carried out remotely via telecare, or via self exercise programmes using exercises learned in advanced and supervised remotely, or by a physiotherapist in the patient’s own home if the absence of a therapist would constitute a loss of opportunity for the patient.
  • Rapid response No. 8: Physiotherapy/rehabilitation at home may be implemented after the acute phase, for a progressive and controlled resumption of low-intensity physical activity (1-3 METs or shortness of breath ≤3 on the Borg scale), continuation of respiratory rehabilitation, resumption of mobilisation and usual functional activities, refeeding, psychological follow-up, in accordance with the patient’s dyspnoea, fatigability and tolerance.
  • Rapid response No. 9: COVID-19 patients, whether in hospital or at home, should be informed that a distance retraining programme focusing on endurance may be necessary, with the aim of achieving a return to work or to physical and social activities.

Context

COVID-19 causes respiratory problems, but also other disturbances (neurocognitive, cardiovascular, gastrointestinal, hepatic and renal, metabolic, psychiatric, etc.). The possible sequelae are secondary to the specific damage caused by the viral infection and the excessive immune response, as well as “non-specific” complications of acute respiratory distress system (ARDS), immobility and prolonged stays in the intensive care unit.

Post COVID-19 ARDS can progress to restrictive respiratory failure due to respiratory muscle weakness, as is the case in SARS (Chan, 2003), and secondary pulmonary fibrosis with impaired diffusion (Chan, 2003 ; Ye, 2020; Bissett, 2012; Pan, 2020) associated with physical deconditioning. The respiratory consequences after the acute phase are still little described in the literature (Huang, 2020; ATS/IDSA, 2019; Wang, 2020; Zhou, 2020; Zhang, 2020). Some patients present cardiovascular effects, such as myocarditis and thromboembolism, which may also cause cardiovascular deconditioning (Madjid, 2020; Inciardi, 2020). Patients with underlying cardiovascular disease have a poorer prognosis (Madjid, 2020; Zheng, 2020; Wu, 2017; Badawi, 2016).

COVID-19 may cause meningo-encephalic, bone marrow and peripheral neurological effects, directly or indirectly (Wu, 2020; Mao, 2020). Some COVID+ patients admitted to the intensive care unit develop ICU-acquired weakness (ICUAW), this being particularly frequent in the event of previous comorbidities (McNeary, 2020; Huang, 2020; Xiang, 2014). Other non-specific complications can be expected in fragile patients, such as decubitus complications (sarcopenia, pressure ulcers, muscle deconditioning (Connolly, 2016), muscle and tendon contractures (Clavet, 2015), joint limitations (Clavet, 2015), psychomotor disadaptation syndrome (Manckoundia, 2014), cognitive and psychiatric disorders, such as post-traumatic stress), along with severe multifactorial denutrition (van Zanten, 2019). During the subacute period, the denutrition may be maintained by anorexia (loss of appetite), itself exacerbated by dyspnoea, anosmia (loss of sense of smell) and ageusia (loss of sense of taste), depressive syndrome and motor disorders impeding feeding.

Studies have revealed that survivors of severe forms of SARS 2003 had persistent pulmonary sequelae up to 15 years later, musculoskeletal sequelae and post-traumatic stress disorder, along with depression and chronic fatigue up to 4 years later (Xiang, 2014; Zhang, 2020; Ngai, 2010). By analogy, it may be assumed that there will be severe pulmonary, neurological (ICUAW), cardiac and musculoskeletal sequelae in some COVID-19 survivors, leading to limitation of activity and social restrictions (Herridge, 2011; Heyland, 2005; Bienvenu, 2018; Fan, 2014).

These rapid responses are drafted on the basis of available knowledge on the date of publication and are liable to evolve on the basis of new data.

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