How can physiotherapists understand, manage and help to prevent Covid-19?

Corona virus disease ( covid-19) caused by virus referred to as SARS- CoV-2 ,has landed up to be a global pandemic affecting people worldwide. It causes illness such as respiratory disease or gastrointestinal disease. It can also lead to death if not treated on time or if the patient is highly immunocompromised. It is therefore important to understand ,identify, control, manage and treat the outbreak of the disease.

Symptoms include respiratory symptoms, pneumonia like illness, fever, cough, breathlessness, fatigue sore throat ,etc are basically seen.

If the symptoms like dyspnea , pain in chest, confusion, arrhythmic pulse, bluish discoloration of lips or face are seen then the immediate medical attention should be sought.

Physiotherapist & all other health care workers are at a higher risk of infection due to the direct contact while managing patients in primary care practice. Therefore, an early assessment of symptoms & signs , a good professional judgment and precautionary measures are necessary  to  prevent the further transmission of virus.

Infection spread – infection spread consists of three components I.e – 

  1. The source – sources are places where infectious agent survives  , like environment & people.
  2. Susceptible person – immunocompromised person,person not vaccinated against infectious agent or patient underlying severe medical conditions.
  3. Transmission of infectious agent – transmission can be indirect or direct, i.e through touch, inhalation, contaminated food, etc ( In order to avoid transmission the airborne precautions, contact precautions & droplet precaution can be taken)

To limit the infectious spread it is important to improve the health care facilities. And ,It is the duty of healthcare professionals worldwide to ensure that they develop neccessary strategies and implement policies that will protect those who may be immunocompromised in order to keep susceptible patients safe from healthcare-associated infections (HAIs). Globally, up to 7% of patients in developed and 10% in developing countries will acquire at least one HAI (health care associated infection)

For managing the diseased condition it is important for the therapist to ,Be informed about the present senario , be well educated with WHO guidelines , be calm and avoid any panicky situation, mange good work force planning to reduce the work load during emergency and ensure safety first.

 Management is divided into three phases

  1. Primary care  ( it is a clinical care includes prevention of transmission and patient education)
  2. Community care (home care)
  3. Hospital care or acute care ( care taken by health care professionals )

Basic goals & guidelines of management 

  1. Patient  education : Therapist has to educate patient and his caretaker or family member about his or her condition & the precautionary measures to be followed according to the stage of disease. Health care maintaining factors such as sleep, nutrition, appropriate activity and mental health should be improved.
  2. Avoid transmission : Use full PEP equipment involving disposable gown, mask, goggle & gloves should be worn before coming in contact with infectious person. Maintain hand hygiene, wear a medical mask, maintain social distancing, if you have any symptoms then kindly seek medical attention at the earliest.
  3. Maintain respiratory health : Very common respiratory syndromes seen among covid-19 patient are mild respiratory illness, pneumonia, ARDS(acute respiratory distress syndrome), sepsis, septic shock. A senior physiotherapist with a senior medical staff should be involved while deciding physiotherapy interventions for the patient. Physiotherapy serves with exercise, mobilization & rehabilitation for the survivors from critical illness. 

    First goal for a therapist is to maintain oxygenation. Non-invasive positive pressure ventilation, aerosol generating procedures and high flow nasal oxygen, oxygen therapy are useful. But ,Rachael Moses, a Consultant Physiotherapist at Lancashire Teaching Hospital, suggests that particular attention should be given during those interventions that place the health care staff at greater risk of contamination for aerial dispersion of droplets.

    Thus , manual ventilation, open suctioning, bronchoscopy are considered to create infection. Specific Aerosol Generating Techniques used in physiotherapy intervention include -Manual Techniques (e.g. Percussion/Manual Assisted Cough) that may lead to coughing and expectoration of sputum ,Use of Positive Pressure Breathing Devices (e.g. IPPB) , Mobilisation Therapy that may help in Coughing and Expectoration of Mucus)If substantial improvement does not occur, the medical team must be alerted because the patient should be in a need for early endotracheal intubation and invasive ventilation within a controlled precautionary environment.

    ( Note: Routine use of NIV is not recommended. as current experience with COVID-19 hypoxic respiratory failure reflects a high associate failure rate . Further , the treatment protocols are decided according to patient condition & response)

    Invasive ventilation- Lung protective mechanical ventilation (MV) is the recommended and is a suitable strategy for the management of acute respiratory failure, which acquires main aim to protect the lung. Few important interventions depending upon the patient requirement  include – positioning , airway clearance ,suctioning ,humidification, nebulizaton, cough assist devices.

    ( note : diaphragmatic breathing, incentive spirometry,respiratory muscle training, etc are contraindications to the treatment.)

    Lung ultrasound can also be used for the better assessment, to asses the bilateral opacities in lung which will further help in better treatment.
  4. Promote hand hygiene :  The Centers for Disease Control and Prevention (CDC) includes activities such as handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis to maintain hand hygiene. You can maintain hand hygiene by using an alcohol based sanitizer, washing hands with soap for 20 seconds , washing hands before eating , handwashing after  an emergency, use of gloves ( use a proper method while removing a glove) hand hygiene is important to prevent the transient flora acquired during the direct contact with patient.
  5. Avoid unccessary physical contact: Avoid physical assessments or avoid exposure to respiratory secretions.
  6. Manage contacts : According to the WHO any person (including healthcare workers) who has been exposed to an individual with suspected COVID-19 is considered a “contact”. E.g healthcare related contact, traveling or working with diseased patient, etc can increase the risk. So it is recommended that health care workers should monitor their contacts on regular basis.
  7. Use of PEP : Medical PPE typically includes face protection, goggles and mask or face shield, gloves, gown or coverall, head cover, and rubber boots.  Use of  PEP is necessary to protect hands, mouth, nasal area, eyes ,face shields and body.PEP must fit the individual wearing it so the proper size of equipment must be worn. Different types of pep are available. Types of gloves include latex including DPNRL, nitrile ,polythene, etc 

    Types of mask like surgical mask,FFP1 , FFP2 or N95, PAPR, etc have different specifications for the use. 
  8. Managing Patient room : Where possible treat the patient in a single room with the door closed. Limit the number of staff present. Reduce or limit the entry and exit from the room during treatment.
  9. Use proper sanitation : proper handwashing stations and alcohol based sanitizer should be available in clinic or hospital. 

    Ensure to maintain a regular cleaning and disinfection of the clinic and equipment, especially after attendance by a COVID-19 patient. Make sure to have an appropriate written infection prevention and control protocols in your clinic or hospital
  10. Passive screening or assessment strategy
  11. Ask questions while booking an appointment: Ask patient whether he or she has recently travel to places with presumed ongoing community transmission of COVID-19?
    Whether he or she had recent contact with anyone with confirmed COVID-19?
    Any recent work in or visits to a healthcare facility where patients with confirmed COVID-19 were being treated? 

    If the answer is NO to all of the above questions they can proceed to make/attend an appointment.

    If the answer is YES to any of the above questions the individual should be asked if they have any of the following symptoms – fever, cough, shortness of breath or any other features or an upper respiratory tract infection such as nasal discharge or frequent sneezing. If the patient has these symptoms then they should not make any appointments.
  12. Workplace planning & staff  protection : staff should be well informed and trained for the ongoing crisis. Team work among all medical practitioners helps to manage condition better. Musculoskeletal physiotherapist can help in rehabilitation phase, cardio respiratory physiotherapist will help in respiratory conditions and ICU management.  

    Physiotherapist who fall in the category – he/ she is pregnant , is immunocompromised, fall in the the age group of 60 or above, suffering from any major health condition , etc are at a greater risk.
  13. Telemedicine consultations : To avoid transmission or if there is unavailability of open clinic, digital strategies are useful to deliver the required services. Good communication skills is must to understand the patient. Some national physiotherapy organisations are also using the  digital practices to provide improved service to the patient.
  14. Maintain healthy immunity :  Healthy diet, nutrition and overall health should be maintained in order to prevent infection.
  15. Promote infectioncontrol programs globally : IPC programmes aim to enhance the work of countries to develop and implement effective technical and behavior modifying interventions. They also help to improve protocols to support health care facilities. 

    REHABILITATION PHASE : 

    The main role of physiotherapist counts in this phase. From preventing secondary complications like deformity, contractures, bed sores to developing overall functional independency. This phase should follow an appropriate approach for rehabilitation and mobility exercise within the Intensive Care Unit, followed by transfer to ward-based rehabilitation.
  • Passive, Active, Active assisted , or Resisted  Range of Motion Exercises to maintain or improve joint ROM & integrity
  • Mobilisation and Rehabilitation (e.g. bed mobility, sitting out of bed, sitting balance, standing hoists, posture control, etc).

Standard precautions for all  :

  • Develop good hand hygine
  • Maintain social distancing
  • Use of personal protective equipment to prevent infection
  • Maintain respiratory hygine
  • Maintain safe sanitization practices
  • Follow safe injection practices
  • Sterilize textiles and laundry carefully, etc to be followed

Futher,

Many new researches by medical practitioners & science experts have commented that the use of hydroxychloroquine which is an anti-malarial drug is found useful in the treatment of corona disease patients. Few recent researchers are also working to show the role and importance of vital skills like chest physiotherapy and early mobilization in the recovery of  covid-19 patients to improve functional independence so that they can step down from ICU fast, and this will increase the early availability of ventilators and beds for other patients. Thus, physiotherapists are of great importance in this context.

Conclusion:

There is no one solution to controlling the spread of infectious diseases, and effective IPC indeed requires government intervention and collaboration between healthcare authorities, individuals and communities in whole. Until certain risk factors are addressed and permanent safety measures are identified.

References –

  • 1.WHO ( World health organization)
  • 2. Physiopedia
  • 3.World confederation for physical therapy (WCPT)
  • 4. journal of physiotherapy

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