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International Journal of Science and Healthcare Research
Vol.5; Issue: 3; July-Sept. 2020
Website: ijshr.com
Review Article ISSN: 2455-7587
Physiotherapy Management of COVID-19
Sharick Shamsi1, Thamer Mugheeb1, Shabana Khan2
1
Senior Physiotherapist at Prince Sultan Military Medical City, Riyadh KSA
2
Physiotherapist at Prince Sultan Military Medical City, Riyadh KSA
Corresponding Author: Sharick Shamsi
ABSTRACT person through respiratory secretions. Large
droplets from coughing, sneezing or
Coronavirus disease 2019, COVID-19 is the 3rd rhinorrhoea land on surfaces within 2 m of
coronavirus infectious disease happening in 20 the infected person. SARS-CoV-2 remains
years was initially defined in Asia, later Middle viable for at least 24 hours on hard surfaces
East Respiratory Syndrome (MERS), & Severe
and up to 8 hours on soft surfaces2. COVID-
Acute Respiratory Syndrome (SARS). COVID-
19 illness expands globally, intensive care unit 19 individuals may have influenza-like,
(ICU) specialists, health care management, respiratory tract infection symptoms such as
authority, plan creators, and researchers need to pyrexia-89%, coughing-68%, extreme
brace for sudden increase of high volume in tiredness-38%, increased mucus-34% and
critical patients. Physiotherapists (PTs), mostly shortness of breath (SOB)-19%3. This new
respiratory PTs, are healthcare specialists coronavirus was linked to a wet seafood
involved in managing and caring for the market, recognized as etiologic agent who is
population of these patients, & play important presently named as SARS-CoV-24,5. Up to-
part in conservative care and treatment, changes date, the virus has quickly spreading-at the
in posture, functional mobility and while time of writing this article-a total of 232,259
invasive mechanical ventilator support is being
infected cases and 167,138 cases recovered
weaned. The objective of the study is to
determine the recent research evidences for the with 2,223 deaths in kingdom of Saudi
management of physiotherapist during COVID- Arabia6.The Global Surveillance Interim
19 pandemic. This study will provide a quick guidance developed by WHO7. (1)-A person
respiratory physiotherapist reference guide to set having severe acute respiratory infection
up treatments for the management in acute symptoms like pyrexia and coughing who
stages of patients suffering from severe COVID- require to admit in the hospital, there is no
19. other cause which completely describes the
clinical symptoms along with travel history
Keywords: COVID-19, Physiotherapy, or stay in China for the period of 14 days
Physiotherapy Management. before beginning of signs. (2)-A person
having any acute respiratory infection with
INTRODUCTION at-least one of given below for the duration
Coronavirus disease-(COVID-19), is of 14 days before occurring symptoms: (i)
a severe acute respiratory syndrome Contacted a positive or possible COVID-19
coronavirus-2, (SARSCOV-2), is a new infected patient or (ii). Served or appeared
coronavirus that appeared in 2019. SARS- in medical canter where cases with positive
COV-2 is extremely infectious disease. It is or possible COVID-19 acute respiratory
different from previous respiratory virus in a illness individuals were being treated.
manner that it seems to have approximately Suspicious person demarcated by Saudi
2-10 days human to human transmission Centre for Disease Prevention and Control
before a person is becoming symptomatic1. (SCDC) as follows7. A individual with acute
The virus is transmitted from person to respiratory illness (ARI) having pyrexia
International Journal of Science and Healthcare Research (www.ijshr.com) 108
Vol.5; Issue: 3; July-September 2020Sharick Shamsi et.al. Physiotherapy management of COVID-19
with coughing & SOB along with one of the have mild symptoms and recover easily,
succeeding: (i) Travel history to China while others may develop respiratory failure
within 14 days preceding to symptoms. (ii) and/or become critically ill and require
A close bodily contact within 14 days with a admission to ICU.
COVID-19 positive patient. The novel Physical therapy might be applicable
COVID-19 guidelines document8 developed for COVID-19 patients presenting with
by SCDC offers health care facilities a profuse airway discharges which patients
different visual triage for acute respiratory cannot clear individually. Patients having
illness having a worksheet for admitting a associated diseases (like neuromuscular
case in isolation provisions scoring more disease, respiratory diseases, lung fibrosis
than six, along with traveling history within etc.) leading to increased secretion or weak
14 days before developing signs, which cough may also be benefited from physical
scores 5 points9. therapy. Physical therapists working in ICU
Amongst health-care workers, can help in clearing airways for patients
physical-therapists, especially respiratory who are ventilated and provide assistance in
therapists, are also playing an important role placing them in proper position2.
in managing and caring novel COVID-19
patients. They are involved in conservative MATERIALS AND METHODS
care, posture correction, mobilization and The articles were identified by
while training to wean of from the weaning looking in the PubMed, Scopus and Pedro
from invasive mechanical ventilator databases to neglect the physiotherapist's
support10. Physiotherapist is a key element work in serious reflection units in the
of the multidisciplinary team (PCD) of management of non-invasive ventilation
active hospital services and intensive care (NIV) without neglecting the risk of
unit. Physiotherapy may be useful in the contamination for health experts.
treatment of respiration, in the treatment of
COVID-19, in addition to proven work to Friendly approach
prevent or delay intensive care. A global specialist in
Therefore, our aim is to provide cardiorespiratory physiotherapy met to
worldwide evidence of physical-therapists quickly prepare clinical recommendations
involvement in managing COVID-19 for the management of COVID-19
infected patients. Viewing the intricacy and physiotherapy. The Creator group met for
frailty of COVID-19 cases, it is the first time on March 20, 2020 to
recommended, when likely, to have as a investigate the imperative for the global
task force, physiotherapists with expertise alignment of physical therapy for the
and/or dedicated training in Respiratory purpose of acute consideration according to
Physiotherapy (RT)10. COVID-19. There have been immediately
made efforts to create an explicit guide for
Purpose: physical therapists in acute viewing
This document has been prepared to provide situations.
information to physiotherapists and acute The AGREE II system was used to
care control the turn of events and to recognize
Health care facilities about the potential role the practicality of these required in the work
of physiotherapy in the management of of the earth and in simple revelation. Direct
hospital admitted patients with confirmed has been designed according to the
and/or suspected COVID-19. COVID-19 is GRADE-ADOLOPMENT process method
a disease caused by a new coronavirus, and the evidence of the decision of
primarily impacting the respiratory system. suggestions and dynamics. The capacity
Symptoms of COVID-19 can range from includes acute and intensive hospital
mild illness to pneumonia. Some people will physiotherapy (all), rehabilitation mediation
International Journal of Science and Healthcare Research (www.ijshr.com) 109
Vol.5; Issue: 3; July-September 2020Sharick Shamsi et.al. Physiotherapy management of COVID-19
in the intensive care unit (all), organization Orientation to physiotherapy
of physical therapy (PT, IB, RG, AJ, RM, Follow your hospital's rules and regulations
ShP ) and systematic audits (PT), CB, CG, regarding referral to physical therapy for
RG, CH, MK, SP, ShP, LV), periodic patients who have been admitted to physical
technique (PT, IB, RG, CH, MK, RM, ShP, therapy in an acute setting12.
LV) and examination of the transmission of Detection and disposition of reported
the disease (CH MK). patients
Web search and individual records 1. The physiotherapist must perform an in-
established recently established rules for the depth assessment of cases remotely
management of COVID-19 for primarily using the electronic documentation
sick patients from universal offices ( e.g., framework.
World Health Organization), a basic order 2. Patients should be classified according
consideration or a distinction between to "Management of patients in
meetings relevant social networks ( e.g. physiotherapy for acute care COVID 19,
ICU) Australian and New Zealand society, 3. Patients who are approved for the
ICU / European ICU) or social regulations airway without indication should
responsible for physiotherapy until March maintain routine physical therapy care in
21, 2020. These have been used to provide accordance with standard contamination
rules advice on transaction proposals on the control precautions13.
main evaluation of the introductory 4. Patients who have had respiratory side
meeting11. effects but who have doubts about
COVID-19 (low isolation) should be
Integration Criteria: classified as "suspected COVID 19"
Patient likely to benefit from physical on- until two tests are reported that
call therapy determine that the tests are negative. .
Patient likely to benefit from on-call 5. Patients who have been approved for
physiotherapy other reasons (heart, injury, orthopedics
Infective exacerbation of COPD with or neurology) and who have indications
acute deterioration for the respiratory tract must be
Controlled asthma with evidence of classified as "suspected COVID 19"
infection, retained secretions, increased until two test determinations are
work of breathing reported in each case. which are
Infective exacerbation of bronchiectasis negative.
or cystic fibrosis with difficulty 6. Patients with respiratory diseases (e.g.,
managing retained secretions shortness of breath, hacking, fever,
Significant consolidation with sputum formation) must always be
compromised respiratory status classified as "suspicious COVID 19", in
Atelectasis causing respiratory any case two provisions for negative
insufficiency laboratory test reports.
Resolving and productive pneumonia
with ineffective cough Considerations on the management of
Recent estuation with associated physiotherapy
All suspected or confirmed cases
retention of sputum and deteriorating
must be reported to the director / supervisor
ABGs/SaO2 or significant risk of
through the group leader with regular
deterioration of respiratory status
updates so that they can be recorded very
well on a COVID physiotherapy tracker /
RESULT
database accessible to all physiotherapy
PART 1: Orientation to physiotherapy
managers and the head of the Department14.
considerations, detection and
management
International Journal of Science and Healthcare Research (www.ijshr.com) 110
Vol.5; Issue: 3; July-September 2020Sharick Shamsi et.al. Physiotherapy management of COVID-19
Suspicious or positive cases of 1. Develop an individual treatment plan
COVID-19 should be assigned to the based on the patient's level of
"COVID-19 Physiotherapy Group" for knowledge, participation and
review. This will help limit / prevent the hemodynamic status.
spread of contamination by making ideal 2. The main objectives of supporting
considerations15. physiotherapy mediations in this phase
are:
Part 2: Physiotherapy management 3. Prevent tangles from lying down
categories 4. Promote oxygen supply.
TYPE A: ventilated, calm / incapacitated 5. Improve freedom of supply
patients Physical therapy management can include
It contains patients who generally do drug implementation, ROM activities and
not feel well, who are calm, unable to act dynamic activation16. Limiting the aerosol
and possibly bowing. Patients with gadgets production process and physiotherapists
ECMO (extracorporeal membrane must assess the risk versus the benefit to
oxygenation): the understanding of ECMO start these processes. In case of essential and
devices depends on their level of sedation extraordinary precautionary measures
and loss of movement control. should be taken followed by these
The main goals of promoting physical procedures.
therapy at this stage are
Limit the confusion of lying on your TYPE C: Non-precisely ventilated
back. patients
Promote oxygen supply. 1. The ESE patients classifications isolated
1. Physical therapy management may based on a conscious level, and practical
include (but not be limited to) distance- freedom.
from-motion (ROM) activity and a 2. The basic goals of physical therapy
recovery situation. (Trials are limited on intercession are
the use of a wide range of exercise Reduce craftsmanship through
practices in anticipation of muscle relaxation.
weakness ICU.) Improve the lung limit.
2. Physiotherapists should limit Promote oxygen supply.
presentation to these patients to avoid Improve the useful limit.
unnecessary use of PPE and the risk of
cross-contamination. TYPE C.1: unconscious and out of
3. Collaborate with MDT to implement service patients
common restoration and insurance The intercession of physical therapy can
methods to limit or stop the integrate latent ROM activities and a
presentation. recovery situation.
4. The decision for physiotherapy The movement and recurrence of
treatment should be based on the physical therapy treatment depend on
patient's ability to rehabilitate himself the patient's rehabilitation potential.
and consideration of the risks in relation Regular recovery from MDT if the
to the benefits. patient adheres to the practice program.
5. Regular correspondence with MD T
relating to the physiotherapy TYPE C.2: conscious, dynamic and ward
management. patients17
The physical therapy mediations may
TYPE B: patients evacuated with include ROM exercises, dynamic
negligible ventilation / sedation strengthening exercises, dynamic
International Journal of Science and Healthcare Research (www.ijshr.com) 111
Vol.5; Issue: 3; July-September 2020Sharick Shamsi et.al. Physiotherapy management of COVID-19
assembly and activities to improve PART 3: Tips for best therapeutic
coordination and balance. practices.
Develop a plan individual treatment Respiratory mediation advice19,20.
depending on the oxygen dependence of Intercession of the respiratory tract as
the patient, the muscle performance and postural infiltration, respiratory exercise
functional freedom, the limit functional strategies and methods of emissions
advanced and advanced autonomy. released to the process of aerosol
Mobilization should be considered a production.
flight production technique because it Avoid / limit this intercession and
can cause piracy or expulsion. The most physiotherapists must weigh the risk
extreme warning must be followed when with the benefits deriving from the
implementing these strategies. initiation of these mediations.
Special portability allows you to stay in If breathing needs to be observed
the isolation area for use by patients precautions in the air are. Before
with COVID 19 in particular. entering the patient's room, you need to
Make sure you have the necessary use the personal protection equipment,
resources (by hand - at work as a device) such as items for the head, the veil
before starting the activation. breathing N95 suits cleaned using
The necessary mobility aids must be disposable, clothing uses disposable, eye
labeled and left in the patient's room, or protection (goggles or face shield),
cleaned and disinfected, if they are to be gloves and shoe covers.
reused for different patients. The N95 respirator should be at their
Avoid the use of specific large devices ease at the point where the customer
as reasonably expected or disinfect them must adapt (eg a seal suction), to limit
carefully every time they are used in the amount of particles that bypass the
patients with COVID 19. channel through the holes between the
Regular recovery from MDT if the skin of the customer and the seal of the
patient adheres to the practice program. breathing mask .
Strict adherence to contamination The respirator must be worn (worn) and
control procedures and precautions removed (removed) effectively and
during preparation. worn during introduction.
For all personal defense equipment
TYPE C.3: conscious, dynamic and free (PPE) must meet the pollution control
patients18 requirements, according to respects the
Physical therapy intercession can appropriate strategies for extraction and
include ROM exercises, dynamic transportation are.
walking exercises and breathing. During patient preparation,
Develop an individual training program physiotherapists must follow the back
that depends on the patient's endurance. method (if possible) and be ≥ 2 m away
Restrict or limit the presentation by from the patient (if possible) to be
instructing the patient in a protected outside the "impact zone" cut line.
training program and asking him or her In patients with acute hypoxicity they
to freely continue the training program. can dyspnoea even in the presence of an
Regular monitoring of the MDT to organization of oxygen > with a 10-15 l
ensure patient compliance with the / min bearing cap remaining. In this
training program and changes based on situation, the use of high flow nasal
FITT rules (repetition, performance, oxygen (HFNO) or continuous positive
duration and type). pressure (CPAP) or non-invasive
ventilation (NIV) can be helpful during
all physical therapy procedures.
International Journal of Science and Healthcare Research (www.ijshr.com) 112
Vol.5; Issue: 3; July-September 2020Sharick Shamsi et.al. Physiotherapy management of COVID-19
When preparing patients with HFNO / ventilation / perfusion ratio to promote .
NIV, consider the possible natural Pads / pads can be used to achieve ideal
distribution of vaporized particles of (eliminated) rest positions.
infection.
The facial veil / deposition veil is ideal Advice on preparing mediations21.
for the nasal cannula when a patient is Mobilization should be seen as a
assembled (facial cover with oxygen vaporized production system because it
flow up to 5 l / min, revised cover up to causes piracy or expulsion. It also
10 l / min of O2 or Venturi veil up to 60 requires close contact of the
% FiO2) to distribute the limit accounts. physiotherapist with patients. In this
A careful blanket covers the patient's sense, it should be a serious alarm are
face. If this veil is dirty, remove it active in the realization of these methods
according to the anti-pollution are and precautions to be followed in the
regulations and use a different cover. air.
If the nasal cannula is the primary When assembling carefully ventilated
alternative, it should be fine in the patients, outrageous considerations must
nostrils and the cannula should be be made to maintain the ventilation
carefully covered. A similar standard is circuit during activation.
the material when the patient uses If the patient is not mechanically
HFNO treatment. ventilated (CPAP / BIPAP), make sure
If the patient is ventilated noninvasively that no air is released before starting a
(CPAP / BIPAP), make sure that no air physical therapy session. We must also
is released before starting a physical pay attention to maintaining the machine
therapy session. In addition, it must have allocation circle.
care to ensure that no separate allocation Patients not exactly ventilated Wear a
of circular machines. veil during physical therapy sessions. If
The VIN cover attached to a circulatory this veil gets dirty, it should be removed
T-barrel can be used for patients with immediately in accordance with the
respirators to improve oxygen disease control standards and covered
immersion during training. with another cover. Make sure the
Limit or a strategic distance from the appropriate resources (hand - in - the -
use of mechanical devices, such as pulse job as a hardware, such as portability),
spirometers, PEEP, seaming, retaining before starting preparation. Avoid
the armor that these processes can sharing material between patients.
theoretically produce in the air and the
increase occurs during breathing. Advice on Infection control rehearses22
In ventilated patients with tracheotomy Examine and follow approaches to control
and precise, only if necessary hospital contamination.
recommended aspiration in closed 1. Remove, by way of example, any device
circuit. Bronchial traction movements / object close to home that contains
must be performed with severe signs. earrings, watches, cables, mobile
Positioning to improve oxygenation: phones, acoustic signals and pens before
The patient is best positioned in a semi- entering the clinic area.
sitting or sitting position while moving 2. The reusable faculty defense equipment
from the reclined position. Variations in must be cleaned and disinfected before
parallel pressure ulcers, in semi-inclined use.
or inclined positions can be very useful. 3. In order to avoid cross-contamination,
The positions should be resolved in an immediate section of the area to be
fixed movements to reduce and the treated and locally defined documents
muscle of the jewels to relax to the are needed .
International Journal of Science and Healthcare Research (www.ijshr.com) 113
Vol.5; Issue: 3; July-September 2020Sharick Shamsi et.al. Physiotherapy management of COVID-19
4. Physiotherapists who treat patients with Postural situations to reduce shortness of
COVID 19 are encouraged to wear clean breath Shortness of breath caused by
coveralls or one-way coveralls that need cheating breathing can decrease and
to be cleaned daily before starting immobilize the patient's limit of activity. By
treatment. placing the patient in a forward tilted
5. Counsellors need to tie their hair and position, we can rationalize the effects of
male specialists are asked to lose facial the respiratory muscles and reduce the
hair. impression of dyspnea. It is recommended
6. All physiotherapists must undergo an to prepare the patient out of bed if the
N95 fit test to determine the correct veil persistent limit allows it.
size.
7. All physiotherapists must complete the Respiratory system to reduce shortness of
"use and remove" skill of the portable breath24:
PSA and hand cleaning. • Breath control - this is supposed to be
done. In the case of the patient's condition
Procedures should be applied during the does not take such a position into account,
acute phase with a blatant alarm23 act on a semi-reclining position (as above).
It is essential that physiotherapy procedures It is important that the patient relaxes the
do not lead to weight gain during the inspiratory flying muscles, in particular
manufacture of breathing. In COVID-19 those of the arms and neck, at this point he
patients, the primary goal of respiratory begins to breathe through the nose (warms
physiotherapy is to reduce the signs of and hydrates the air), at this point he plays a
shortness of breath and improve lung moderate relaxation and widens at the
capacity, neutralizing the discomfort caused expiration with the establishment of
by respiratory illusions and immobilization, adequate airways (lower thoracic breathing
reduction of disability, improvement of and stomach). Breathing should be calm
personal satisfaction and reduction of the (shallow, slow).
level of nervousness and discouragement of • The conclusion must be made with the
balance. After completing a physical alleged relaxing lip of the lips. This method
therapy assessment, such as examining can be added for normal breathing while
airway conditions, the physiotherapist must you rest and keep this movement in mind. It
decide questions that are useful in the serves to slightly fix the lips while you
patient's treatment process based on clinical exhale.
purposes. The point of administration of Physiotherapists work in a variety of
physical therapy at this stage of the environments and regardless of how the CPI
infection movement may include: can be the same for everyone and in all
Reduce unnecessary respiratory environments, the rest of the work will help
activities (for example, with respiratory reduce the need to do is in clinical centres,
strategies and places that reduce able to distinguish the activity of a
wheezing, the oblique position, the physiotherapist in any context. In the basic
course). idea (e.g. private offices, joint specialist
clean the rest of the program, studies or general practitioners), the
increase in the lung limit, highlight will be the rapid and visible
improve the gas trade, identification and confirmation of cases. In
gradually mobilize and expand the taking care of society (e.g. at home), the
campaign, supplement is to show patients and
General well-being acts, prevents the effects healthcare professionals. In serious
of immobilization and increases resistance reflection (for example, in the clinical
to physical movements. centre), the complement will be in the
organization of respiratory reactions.
International Journal of Science and Healthcare Research (www.ijshr.com) 114
Vol.5; Issue: 3; July-September 2020Sharick Shamsi et.al. Physiotherapy management of COVID-19
DISCUSSION risk of transmission due to the
The current epidemiological contamination that is now Observe the
situation is an excellent test for any clinical coronavirus SARS 2 and in this way a risk
expert. Now it is estimated that about 15 to is conceivable by the physiotherapists who
20 percent of patients with Covid-19 need to use them.
be hospitalized and 5-6 percent need a
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