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.

Figure 1

The flow of patients with COVID-19 with their signs and symptoms before^,, and during hospital admission^,,,,,; the severity classification^, and the physical therapy goals during hospital stay.^,

Figure 2

Summary of recommendations for hospital-based physical therapists managing patients with COVID-19.

Figure 3

Criteria for safety of treatment according to Sommers et al. Level of evidence of the literature and clinical expertise: level 1 = recommendation based on evidence of research of level A1 (systematic review) or at least 2 independent studies of level A2 (randomized controlled trial of good quality and size); level 2 = recommendation based on 1 study of level A2 or at least 2 independent studies of level B (randomized controlled trial of moderate or weak quality or insufficient size, or other comparative studies, eg, patient controlled and longitudinal cohort studies); level 3 = recommendation based on 1 study of level B or level C (non-comparative studies); level 4 = recommendation based on expert opinion.

Figure 4

Expert opinion suggestions for active mobilization sessions in patients who are critically ill with COVID-19 in the intensive care unit (ICU), Phase B.

Figure 5

Expert opinion suggestions for active mobilization sessions in patients who are severely ill with COVID-19 in the COVID ward.