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Role of the Physiotherapist in COVID-19


This content has been generously supported by World Physiotherapy


Physiotherapists (Physical Therapists) and other clinicians often have direct contact with patients, which makes them susceptible to the transmission of infectious diseases. Physiotherapists are also often first contact practitioners, which means that they are in a position to take responsibility for the early identification of infectious disease and/or managing workload in primary care settings. It is therefore very important for physiotherapists and other health professionals to be familiar with COVID-19 and how to prevent its transmission, and understand how they can be involved in workforce planning. They must use their professional judgment to determine when, where, and how to provide care, with the understanding this is not always the optimal environment for care, for anyone involved[1]. At the same time, consideration must be given to the fact that our profession plays a crucial role in the health of our society, and there are people in our communities whose health will be significantly impacted by disruptions to care.

Key considerations:

  1. Stay current – Ensure that you are well read on current COVID-19 guidance. The WHO and the CDC have good evolving resources, also check with your local authority.
  2. Stay calm – Have an objective view of the crisis we are facing. People, for example, staff and patients, may look to you as a leader to provide information to help them make decisions and also provide reassurance that we can take care of them at this time of need.
  3. Minimise exposure in your setting – review infection prevention and control (IPC) guidelines, practice social distancing, implement triage strategies, reschedule non-urgent care, consider digital service delivery, consider closures, for example, if you don’t have PPE available.
  4. Get involved in workforce planning – where appropriate offer services to reduce the load on emergency departments and frontline practitioners.
  5. Get educated – all staff should be trained in COVID-19 related strategies and procedures, including rehearsals of potential scenarios, such as a COVID-19 case being identified on the clinic premises.

Physiotherapists work in many different settings and although IPC will be the same for everyone and any setting can potentially contribute to reducing the workload of hospitals, the role of the physiotherapist in each setting may differ. In primary care (i.e. private clinics, physician shared or GP practices) the emphasis will be triage and early identification of cases. In community care (i.e. in the home) the emphasis will be on educating patients and carers. In acute care (i.e. the hospital setting) the emphasis will be on the management of respiratory symptoms.

Primary (Clinic) Care

There are two main considerations in primary care:

  1. Avoid transmission
  2. Provide education

Avoid Transmission

To avoid the transmission of COVID-19, the following are recommended practices for clinical staff:

1. Adhere to basic protective measures at all times

  • Perform hand hygiene frequently with an alcohol-based hand rub if your hands are not visibly dirty or with soap and water if hands are dirty.
  • Avoid touching your eyes, nose and mouth.
  • Practice respiratory hygiene by coughing or sneezing into a bent elbow or tissue and then immediately disposing of the tissue.
  • Based on current advice, the following people should wear medical masks:
    • Health workers
    • People who have COVID-19 symptoms
    • Those looking after people with confirmed or suspected COVID-19
    • People aged 60+ and those with underlying health conditions (where COVID-19 is widespread and social distancing of at least 1m cannot be achieved)
  • People should wear fabric masks when:
    • COVID-19 is widespread
    • Social distancing of greater than 1m cannot be achieved
    • Those in close contact with others


  • Maintain social distancing (a minimum of 1 m/3 ft[3]) and according to the CDC at least 2m/6ft from individuals with respiratory symptoms [4].
  • If you have a fever, cough and have difficulty breathing seek medical care.

2. Promote respiratory, hand and clinic hygiene

  • Ensure that you have appropriate written infection prevention and control protocols in your practice setting and communicate these protocols to all staff.
  • Place additional signage in and around the clinic to encourage regular hand washing. You can get these from the WHO.
  • Ensure that alcohol-based hand sanitisers and/or handwashing stations are available.
  • Ensure regular cleaning and disinfection of the clinic and equipment, especially after attendance by a COVID-19 patient.

3. Provide up to date information about the virus to staff and patients

  • Share educational messages with patients.
  • Review and amend information on your clinic website, appointment reminders and appointment protocols.
  • Signage, about hand and respiratory hygiene and other basic protective measures, should be displayed prominently at the first point of contact to the service such as reception areas, waiting rooms. Signage should also prompt visitors, staff, volunteers and patients to self-identify if they are at risk of having COVID-19.

4. Avoid unnecessary direct physical contact with individuals who may be infected

  • Don’t perform physical assessments.
  • Avoid exposure to respiratory secretions.
  • Encourage patients with symptoms to stay at home.

5. Liaise with staff and local public health specialists

  • Stay up to date with the latest information on the COVID-19 outbreak through WHO updates or your local and national public health authority.
  • Liaise with local public health specialists to keep up to date with local guidelines.
  • Hold regular team meetings with staff to review this information and provide any updates.

6. Initiate early identification strategies

If your clinic remains open, physiotherapists should undertake active screening (asking questions) and passive screening (signage) of patients for COVID-19.

– On booking an appointment

If an individual phones to make an appointment or has concerns about COVID-19 in advance of attending an appointment, they should be asked if they have had:

  • recent travel to places with presumed ongoing community transmission of COVID-19.
  • recent contact with anyone with confirmed COVID-19.
  • 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 individual has any of the above symptoms then they should not make an appointment and should be advised about local authority guidelines.
  • If the individual does not have any of the above symptoms, it is ok for them to make an appointment BUT they should be advised to follow local guidelines for people who may be at risk of transmission (which may include quarantine).

– On attending clinic

Patients with respiratory symptoms and relevant travel history may also be identified when they book in at reception for example by direct questioning or incorporating a question on symptoms of cold or flu-like illness and travel in registration paperwork. Ask the patient about

  1. recent travel to places with presumed ongoing community transmission of COVID-19.
  2. recent contact with anyone with confirmed COVID-19.
  3. recent work in or visits to a healthcare facility where patients with confirmed COVID-19 were being treated.
  4. 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 concerns about possible COVID-19 are identified in the course of a consultation:

  1. Isolate the patient away from other patients. Ideally, this should be an unoccupied room with the door closed. If a room is not available the person should be asked to wait in their car or be seated in an area separated by at least 6 feet or 2 meters from other individuals.
  2. Initiate basic protective procedures and use personal protective equipment (PPE: gowns, gloves, medical mask and eye protection)[5].
  3. Provide the patient with tissues, a surgical face mask and alcohol hand rub.
  4. Follow local authority guidelines to arrange COVID-19 assessment.
  5. If the patient is to return home, they should quarantine themselves while awaiting home assessment. Patients should not travel home by taxi, public transport or walking. The patient may travel home by car if the patient feels well enough to drive or can be driven by a person who has already had significant exposure, who is aware of the risks and who is willing to drive them.
  6. Follow clinic cleaning and disinfection protocols once the patient has left the clinic.

Provide Education

Physiotherapists have a responsibility to share knowledge on preventing transmission of COVID-19. This should be done at any patient interaction be it in the clinic, on the phone or via digital consultation.

In addition to this, many people will face weeks of isolation in quarantine and promoting health at these times will be key. Physiotherapists are well placed to provide and should be proactive in offering health maintenance strategies including:

  • Activity – taking into consideration each particular persons individual situation and health condition, provide advice on how to take appropriate activity.
  • Nutrition – good nutrition is key to boosting immunity.
  • Sleep – again, sleep is key to keeping a strong immune system. People should be advised to maintain normal sleep patterns and good sleep hygiene.
  • Mind – the longer people are isolated the more mental health will suffer, particularly for people living on their own. Be sure to offer strategies for good mental health by advising people to keep mentally active with learning and playing, maintain social relationships using online video conferencing tools such as WhatsApp and FaceTime.

Community (Home) Care

In the situation where a person has suspected COVID-19 with mild symptoms, care can be provided at home. It is suggested that a healthcare professional assesses whether the residential area is suitable for providing the necessary care. This might be particularly relevant when the person has co-morbidities, reduced functioning, disabilities and/or is elderly. The WHO has provided advice for providing home care for a case with mild symptoms[6].

Factors to Consider

  • Will the patient and family be able to adhere to the recommended precautions as part of home care isolation (adhere to hand and respiratory hygiene principles, cleaning of the home environment, limitation of movement around the home).
  • Will the patient and family be able to correctly handle safety concerns that arise while isolating at home (accidental ingestion or fire hazards that may be associated with the use of alcohol-based hand sanitisers).
  • A communication link between the patient, the healthcare professional and the public health authority of a specific area/country should be confirmed.
  • Education of the patient and family members of basic hand and respiratory hygiene principles.
  • Provision of ongoing support to the patient and family.

Recommendations for Patients, Families and Carers

  • Patients should remain in a well-ventilated room (open windows and doors).
  • Limit movement of patients around the home and limit shared spaces.
  • Shared spaces should be well-ventilated at all times.
  • Family or household members should stay in different rooms and keep a distance of at least 1m from the ill family/household member.
  • Limit the number of caregivers and no visitors allowed until the patient has recovered and has no more signs and symptoms.
  • Proper hand hygiene is essential after any contact with the patient or their immediate environment.
  • The patient should wear a medical mask to contain respiratory secretions.
  • Respiratory hygiene should be practiced – cover mouth or nose with a disposable paper tissue when coughing or sneezing and dispose of appropriately. When tissue isn’t available, sneeze or cough into the bend of the elbow and not into hands.
  • Caregivers are advised to wear medical masks when providing care to the patient.
  • Avoid direct contact with bodily fluids.
  • The patient should use dedicated linen and eating utensils – these should be cleaned with soap and water after use.
  • Surfaces in the patient’s room or areas where the patient is should be cleaned and disinfected. It is recommended to use regular household cleaning products first and then a household disinfectant afterwards.
  • Bathroom and toilet surfaces should be cleaned at least once daily.
  • The patients’ clothes and linen may be washed with regular laundry products and water. Machine wash at temperatures of 60 – 90 ℃.
  • All gloves and masks used during home care isolation should be disposed of as infectious waste.
  • Avoid any exposure to contaminated items used by the patient (toothbrushes, towels, linen, wash clothes, eating utensils, etc).
  • Healthcare professionals tending to patients under home care should be familiar with and be able to select, use, remove and dispose of the correct personal protective equipment (PPE) to be used[7].


Acute (Hospital) Care

A minority group of people will present with more severe symptoms of COVID-19 and will need to be hospitalised, most often with pneumonia. In some instances, the illness includes severe pneumonia, ARDS, sepsis and septic shock[9]. In these cases, the physiotherapist may find themselves involved in the respiratory care of the patient.

Safety First

Specific advice for front line clinicians:

  1. Ensure that there are enough supplies and access to appropriate Personal Protective Equipment (PPE) for front line staff.
  2. Ensure that staff have an opportunity to take adequate breaks during and between shifts.
  3. Ensure access to appropriate support services for the psychological health of staff.

As with any contagious respiratory condition, care must be taken to protect yourself and those in the immediate environment by following strict protocols and ensuring the use of PPE as well as taking the following steps[10]:

  • Where possible treat the patient in a single room with the door closed.
  • Limit the number of staff present.
  • Minimise entry and exit from the room during treatment.

Respiratory Interventions

As with any patient displaying respiratory symptoms, it may be necessary to provide treatment to relieve symptoms and improve function. The secretion load of people with COVID-19 is low so they don’t usually require invasive or intensive airway clearance techniques[11]. Physiotherapy support is more focused on non-invasive ventilation support measures and then the rehabilitation phase[11].

  • In the mild and moderate stages of disease, normal oxygen supportive measures (facemask oxygen) may be advantageous.
  • Patients with severe pneumonia often need oxygenation support. High flow nasal oxygen** is recommended at this stage, in conjunction with negative pressure room (if available)[12]. Nebulisation is not recommended[12].
  • Some patients may go on to develop ARDS. Noninvasive ventilation (NIV) is not routinely recommended[12] and these patients usually warrant intubation with mechanical ventilation. Prone positioning may assist ventilation and closed suctioning is recommended[12]. Extracorporeal membrane oxygenation may be indicated in patients with refractory hypoxia.

During the acute phase of COVID 19, Lazerri et al suggest any interventions that could potentially increase the risk of breathing are contraindicated and should be avoided[13]. Once stable and no longer in the , if indicated the main goal in respiratory physiotherapy is to mobilise secretions and ease the work of breathing. Interventions may include techniques such as positioning, autogenic drainage, deep breathing exercises, breath stackingactive cycle of breathing mobilisation and manual techniques (e.g. percussion, vibrations, assisted cough) to aid sputum expectoration**[14][15][16][10]. These interventions can be performed at any stage of the disease where appropriate and safe to perform.

**Particular attention should be given during those interventions that place the health staff at greater risk of contamination for aerial dispersion of droplets, such as sputum induction, open suctioning, nebulisers, high flow oxygen, NIV, as these are a potential route for transmission for the virus[17]. Airborne PPE must be used.

This section on respiratory interventions is a summary, please read the Respiratory Management of COVID-19 for more specific information.

Management of 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”. These contacts are advised to monitor their health for 14 days from the last day of possible contact in order to take appropriate action if necessary.[6]

The WHO[18] describes a contact as a person who is involved in any of the following from 2 days before and up to 14 days after the onset of symptoms in the patient:

  • Providing direct care for patients with COVID-19 disease without using proper personal protective equipment.
  • Staying in the same close environment as a COVID-19 patient (including sharing a workplace, classroom or household or being at the same gathering).
  • Travelling in close proximity with (that is, having less than 1 m separation from) a COVID-19 patient in any kind of conveyance.

The following counts as exposure to contacts:

  • Healthcare-related contact – providing direct care to patients with COVID-19.
  • Working in close proximity or sharing a classroom with a person with COVID-19.
  • Travelling with a person(s) with COVID-19 in any kind of vehicle.
  • Living in the same household as a person with COVID-19 within 14 days after the onset of the person’s symptoms.

Healthcare professionals should monitor their contacts on a regular basis. Recommendations if a contact develops symptoms[6]:

  • Notify the relevant healthcare authorities as well as the medical facility where symptomatic contact will be directed to.
  • Symptomatic contact should wear a medical mask while travelling to seek care.
  • The symptomatic contact should avoid taking public transport if possible – an ambulance can be dispatched or if the person is being transported via private vehicle, all the windows should be opened (vehicle well-ventilated).
  • The symptomatic contact should be advised on proper hand and respiratory hygiene as well as to keep a distance of at least 1 m from others.
  • Clean and disinfect any surfaces that could have been contaminated with respiratory secretions during transport of the symptomatic contact with cleaning products and then with a disinfectant.

Workforce Planning

Physiotherapists may find themselves in a position to reduce the workload in emergency departments and/or divert staff to contribute to the care of hospitalised COVID19 cases. The key to workforce planning is to identify what the unique contribution is of your clinic and/or staff, and what your generic contribution is to pandemic planning:

  • Respiratory and on-call teams can be mobilised to the intensive care units and medical wards.
  • Musculoskeletal physiotherapists can contribute in the rehabilitation phase to assist recovered COVID-19 cases return to full function.
  • Outpatient departments in hospitals could assist with acute/urgent injury cases that present to emergency departments to keep them out of the contagious environments, such as keeping them out of COVID-19 screening queues.
  • Service providers can set up telemedicine services to keep people socially distanced and out of contagious environments.

Protecting Staff

It is important when planning services that physiotherapists who fall into the high-risk categories should avoid contact with Covid-19 patients. These include members of the team that[19]:

  • Are pregnant – although at present the risks from COVID-19 are unconfirmed it is known that exposure to any respiratory disease carries an increased risk of complications for mother and baby.
  • Have a known chronic respiratory illness
  • Are immunosuppressed or have immune deficiences
  • Are over the age of 60 years
  • Have an underlying health condition such as heart disease, lung disease or diabetes
  • Have immune deficiencies, such as neutropenia, disseminated malignancy and conditions or treatments that produce immunodeficiency [12].

Telemedicine Consultations

To reduce transmission or in the case where a clinic is forced to close, you may consider implementing digital strategies to continue the delivery of your service. There are currently no established or recognised global standards or agreement for delivering physiotherapy care digitally. However, the overall emerging evidence appears to indicate that digital technologies are providing new opportunities for the physical therapy profession to deliver high-quality and acceptable care to users of their service in ways that can have benefits for all[20]. Some national physiotherapy organisations are welcoming the use of digital practices where it enhances the service to the patient[21]. To implement telemedicine a variety of approaches can be used such as the use of general communication tools such as email, chat/messaging and video conferencing and/or physiotherapy specific platforms such as online exercise prescription tools. It is important to take into account the barriers to access the use of these tools may present for some patients and provide support where required if possible.[22] Review and follow all national or state laws (practice acts/legislations) regarding telemedicine or telehealth services.


Rehabilitation After COVID-19

Rehabilitation in the recovery phase is going to be a key responsibility of physiotherapists in collaboration with the multidisciplinary team, including occupational therapists, speech and language therapists, dieticians and psychologists.


Related articles

Coronavirus Disease (COVID-19) – PhysiopediaIntroduction to COVID-19 This content has been generously supported by World Physiotherapy The World Health Organisation (WHO) has declared the coronavirus disease 2019 (COVID-19) a pandemic[1]. A global coordinated effort is needed to stop the further spread of the virus. A pandemic is defined as “occurring over a wide geographic area and affecting an exceptionally high proportion of the population.”[2] The last pandemic reported in the world was the H1N1 flu pandemic in 2009. On 31 December 2019, a cluster of cases of pneumonia of unknown cause, in the city of Wuhan, Hubei province in China, was reported to the World Health Organisation. In January 2020, a previously unknown new virus was identified[3][4], subsequently named the 2019 novel coronavirus, and samples obtained from cases and analysis of the virus’ genetics indicated that this was the cause of the outbreak. This novel coronavirus was named Coronavirus Disease 2019 (COVID-19) by WHO in February 2020.[5] The virus is referred to as SARS-CoV-2 and the associated disease is COVID-19[6]. As of 15 May 2020, over 4,444,670 cases have been identified globally in 188 countries with a total of over 302,493 fatalities. Also 1,588,858 were recovered Live data can be accessed here. [7] [8] [9] What is Coronavirus? Coronaviruses are a family of viruses that cause illness such as respiratory diseases or gastrointestinal diseases. Respiratory diseases can range from the common cold to more severe diseases eg Middle East Respiratory Syndrome (MERS-CoV) Severe Acute Respiratory Syndrome (SARS-CoV)[10]. A novel coronavirus (nCoV) is a new strain that has not been identified in humans previously. Once scientists determine exactly what coronavirus it is, they give it a name (as in the case of COVID-19, the virus causing it is SARS-CoV-2). Coronaviruses got their name from the way that they look under a microscope. The virus consists of a core of genetic material surrounded by an envelope with protein spikes. This gives it the appearance of a crown. The word Corona means “crown” in Latin. Coronaviruses are zoonotic[11], meaning that the viruses are transmitted between animals and humans. It has been determined that MERS-CoV was transmitted from dromedary camels to humans and SARS-CoV from civet cats to humans[10].  The source of the SARS-CoV-2 (COVID-19) is yet to be determined, but investigations are ongoing to identify the zoonotic source to the outbreak[12]. Clinical Presentation Typically Coronaviruses present with respiratory symptoms. Among those who will become infected, some will show no symptoms. Those who do develop symptoms may have a mild to moderate, but self-limiting disease with symptoms similar to the seasonal flu[13]. Symptoms may include:  Respiratory symptoms Fever Cough Shortness of breath Breathing difficulties Fatigue Sore throat A minority group of people will present with more severe symptoms and will need to be hospitalised, most often with pneumonia, and in some instances, the illness can include ARDS, sepsis and septic shock[13][14].  Emergency warning signs where immediate medical attention should be sought[15] include: Difficulty breathing or shortness of breath Persistent pain or pressure in the chest New confusion or inability to arouse Bluish lips or face High-Risk Populations The virus that causes COVID-19 infects people of all ages. However, evidence to date suggests that two groups of people are at a higher risk of getting severe COVID-19 disease[16]: Older people (people over 70 years of age) People with serious chronic illnesses such as: Diabetes Cardiovascular disease Chronic respiratory  disease Cancer Hypertension Chronic liver disease The WHO has issued and published advice for these high-risk groups and community support. This is to ensure that these high-risk populations are protected from COVID-19 without being isolated, stigmatised, left in positions of increased vulnerability or unable to have access to basic provisions and social care. WHO advice for high-risk populations[16]: When having visitors at your home, extend  “1-meter greetings”, like a wave, nod or bow. Request that visitors and those who live with you, wash their hands. Clean and disinfect surfaces in your home (especially those that people touch a lot) on a regular basis. Limit shared spaces if someone you live with is not feeling well (especially with possible COVID-19 symptoms). If you show signs and symptoms of COVID-19 illness, contact your healthcare provider by telephone, before visiting your healthcare facility. Have an action plan in preparation for an outbreak of COVID-19 in your community. When you are in public, practice the same preventative guidelines as you would at home. Keep updated on COVID-19 through obtaining information from reliable sources. Transmission of COVID-19 Evidence is still emerging, but current information is indicating that human-to-human transmission is occurring. The routes of transmission of COVID-19 remains unclear at present, but evidence from other coronaviruses and respiratory diseases indicates that the disease may spread through large respiratory droplets and direct or indirect contact with infected secretions[17]. The incubation period of COVID-19 is currently understood to be between 2 to 14 days[15]. This means that if a person remains well after 14 days after being in contact with a person with confirmed COVID-19, they are not infected. [18] Preventing Transmission The WHO suggests the following basic preventative measures to protect against the new coronavirus[19][20] Stay up to date with the latest information on the COVID-19 outbreak through WHO updates or your local and national public health authority. Perform hand hygiene frequently with an alcohol-based hand rub if your hands are not visibly dirty or with soap and water if hands are dirty. Avoid touching your eyes, nose and mouth. Practice respiratory hygiene by coughing or sneezing into a bent elbow or tissue and then immediately disposing of the tissue. Wear a medical mask if you have respiratory symptoms and performing hand hygiene after disposing of the mask. Maintain social distancing (approximately 2 meters) from individuals with respiratory symptoms. If you have a fever, cough and difficulty breathing seek medical care. [21] Diagnostic Procedures A COVID-19 diagnostic testing kit has been developed and is available in clinical testing labs[22]. The gold standard for testing for COVID-19 is Reverse Transcription Polymerase Chain Reaction (RT-PCR). However, current data suggest that RT-PCR is only 30-70% effective for acute infection, this may be due to incorrect use of lab kits or not enough virus in the blood at the early stages of testing. Plus, the availability of testing will vary from country to country. The CDC recommends that any person who may have had contact with a person who is suspected of having COVID-19 and develops a fever and respiratory symptoms listed above are advised to call their healthcare practitioner to determine the best of course of action[23].  The main criteria for testing are:[24] Location Age Medical history and risk factors Exposure to the virus and contact history Duration of symptoms If the above criteria are met it is advised that the following testing procedure is followed:[22] Collect and test upper respiratory tract specimens, using a nasopharyngeal swab If available testing of lower respiratory tract specimens If a productive cough is evident then a sputum specimen should be collected For patients who are receiving invasive mechanical ventilation, a lower respiratory tract aspirate or broncho-alveolar lavage sample should be collected Imaging may be useful in identifying patients with COVID-19 which is especially relevant in places with good access to imaging technology but poor access to reliable and quick laboratory testing[25]. Chest X-rays are not especially sensitive for COVID-19, but chest CT gives a much more detailed view appears to have good sensitivity in initial stages of the disease[26]. However chest CT or X-ray is not currently recommend as a diagnostic method as they can easily be confused with other infections such as H1N1, SARS, MERS and seasonal flu. Lung ultrasound is also emerging as a valuable diagnostic testing procedure. According to the CDC, even if a chest CT or X-ray suggests COVID-19, viral testing is the only specific method for diagnosis[27]. Myocardial injury tends to affect COVID‐19 severity and mortality. A meta-analysis showed patients with high cardiac troponin I (>13.75 ng/L) and aspartate aminotransferase levels (>27.72U/L) combined with either advanced age (>60 years) were more likely to develop adverse outcomes. Evaluating cardiac injury biomarkers may assist in identifying patients at the highest risk and leading to specific therapeutic interventions[28]. Case Definitions The definitions used by the WHO in COVID-19:[29] Suspect case: Patient with acute respiratory illness (fever and at least one other symptom such as cough or difficulty breathing (shortness of breath)) AND with no other aetiology that explains symptoms AND a history of travel to a country/area that reported transmission of SARS-CoV-2 virus OR Patient with acute respiratory illness AND who have been in contact with a confirmed or probable COVID-19 case in the last 14 days prior to the onset of signs and symptoms OR Patient with severe respiratory illness (fever and at least one other symptom such as cough or difficulty breathing (shortness of breath)) AND that requires hospitalisation AND with no other aetiology that explains clinical picture/presentation of the patient Probable case: A probable case is a suspected case for whom the report from laboratory testing for the COVID-19 virus is inconclusive. Confirmed case: A confirmed case is a person with laboratory confirmation of infection with the COVID-19 virus, irrespective of clinical signs and symptoms. Differential Diagnosis Differential diagnosis should include the possibility of a wide range of common respiratory disorders such as: Other Coronaviruses (SARS, MERS) Adenovirus Influenza Human metapneumovirus (HmPV) Parainfluenza Respiratory syncytial virus (RSV) Rhinovirus (common cold) Bacterial pneumonia, mycoplasma pneumonia (MPP) and chlamydia pneumonia[30]. Differentiation should also be made from lung disease caused by other diseases[31]. A CT scan has great value in early screening and differential diagnosis for COVID-19 [32]. Management / Interventions In the case of mild to moderate symptoms the following considerations should be taken into account: Early identification – Clinicians, especially physiotherapists, are most often in direct contact with their patients, which can make them infected or infected by others. It is therefore very important for physiotherapists and other health professionals to be familiar with the condition of COVID-19, how to identify it and how to prevent it. Strategies for infection prevention and control (IPC) – Suspect, probable and confirmed cases should be educated on IPC strategies to prevent transmission of the disease and health management strategies for quarantine. Find out more about the role of the physiotherapist in COVID-19 here. For hospitalised patients the WHO highlights several considerations[14]: Recognising and sorting patients with severe acute respiratory disease – Early recognition of suspected patients allows for timely initiation of IPC. Early identification of those with severe manifestations allows for immediate, optimised supportive care treatments and safe, rapid admission (or referral) to the intensive care unit according to institutional or national protocols. For those with mild illness, hospitalisation may not be required unless there is a concern for rapid deterioration. All patients discharged home should be instructed to return to the hospital if they develop any worsening of illness. Strategies for infection prevention and control (IPC) – IPC is a critical and integral part of the clinical management of patients and should be initiated at the point of entry of the patient to the hospital. Standard precautions should always be routinely applied in all areas of health care facilities. Standard precautions include hand hygiene; use of PPE to avoid direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin. Standard precautions also include prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment. Early supportive therapy and monitoring – Give supplemental oxygen therapy immediately to patients with severe acute respiratory illness (SARI) and respiratory distress, hypoxaemia, or shock. Use conservative fluid management in patients with SARI when there is no evidence of shock. Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis, and apply supportive care interventions immediately. Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and appreciate the prognosis. Communicate early with the patient and family. Collection of specimens for laboratory diagnosis – Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally before antimicrobial therapy. Collect specimens from both the upper respiratory tract (nasopharyngeal and oropharyngeal) and lower respiratory tract. Management of respiratory failure and ARDS – Recognise severe hypoxaemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy. In the case of respiratory failure, intubation and protective mechanical ventilation may be necessary[33]. Non-invasive techniques can be used in non-severe forms, however, if the scenario does not improve or even worsen within a short period of time (1–2 hours) then mechanical ventilation must be preferred[33]. Management of septic shock – Haemodynamic support is essential for managing septic shock[33]. Prevention of complications – Implement the following interventions to prevent complications associated with a critical illness such as: reduce days of invasive mechanical intervention reduce the risk of ventilator-associated pneumonia reduce the risk of venous thromboembolism reduce the risk of pressure ulcers reduce the incidence of ICU related weakness Treatment interventions – There is no current evidence from RCTs to recommend any specific anti-nCoV treatment for patients with suspected or confirmed COVID-2019 infection. A recent review stresses the importance of a multi-professional approach in treating critically ill children and adolescents with SARS-CoV-2 infection. It proposes the analysis of radiologic findings, appropriate fluid therapy, hemodynamic support, early nutritional therapy, and physiotherapy; however, other therapeutics such as corticosteroids, antiviral therapy, antithrombotic therapy, and use of immunoglobulins can be considered after the substantial evaluation[34]. For more details on the management of hospitalised patients see this WHO document. Find out more about the physiotherapy management of people with COVID-19 here: Role of the physiotherapist in COVID-19 Respiratory management of COVID-19 Use of Personal Protective Equipment The type of personal protective equipment (PPE) used when caring for COVID-19 patients will vary according to the setting and type of personnel and activity.  Healthcare workers involved in the direct care of patients should use the following PPE: gowns, gloves, medical mask and eye protection (goggles or face shield).  Specifically, for aerosol-generating procedures (e.g., tracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy) healthcare workers should use respirators, eye protection, gloves and gowns; aprons should also be used if gowns are not fluid resistant[35].  Among the general public, persons with respiratory symptoms or those caring for COVID-19 patients at home should receive medical masks. For asymptomatic individuals, wearing a mask of any type is not recommended. Wearing medical masks when they are not indicated may cause unnecessary cost and a procurement burden and create a false sense of security that can lead to the neglect of other essential preventive measures[36]. WHO has provided a document that specifically outlines the recommended type of personal protective equipment (PPE) to be used in the context of COVID-19 disease, according to the setting, personnel and type of activity, you can see it here. In the case of a pandemic, supplies of PPE may become limited. Strategies to optimise the availability of personal protective equipment (PPE) include[20]: Minimise the need for PPE by considering telemedicine (providing health care remotely), using physical barriers such as glass or plastic windows e.g. in receptions, restricting healthcare workers not involved in care from being in close proximity with COVID-19 patients. Ensure PPE use is rationalised and appropriate by assessing the risk of exposure and transmission. Coordinate PPE supply chain mechanisms. Special Population Considerations Older People Although the virus can infect people of all ages, evidence suggests that older people (those of 60 years old) have an increased risk of developing a severe form of the disease.[16] This may be due to: Ageing is associated with a decline in immune function Higher risk of co-morbidities (Diabetes, Heart Disease, Lung Conditions, Cancer) Residence/Location – Many older people live in care homes or nursing facilities, where the disease can spread more rapidly To read more about Infection Control in Older Adults see here Disabled People with disability may be at greater risk of contracting COVID-19 because of[37]: Barriers to implementing hand hygiene. Difficulty in enacting social distancing. The need to touch things to obtain information from the environment or for physical support. Barriers to accessing public health information. Barriers to accessing healthcare. This WHO document, Disability considerations during the COVID-19 outbreak, outlines actions for authorities, healthcare workers, disability service providers, the community, people with disability and their household. Pregnant Women and Newborns The risk for adverse maternal and neonatal outcomes associated with COVID-19 is largely unknown, but medical experts suspect symptoms of COVID-19 may be more severe in pregnant woman compared to non-pregnant women[38]. This may be due to changes in their bodies and immune systems pregnant women can be badly affected by some respiratory infections[39]. Women with COVID-19 can breastfeed and have close contact with their newborn, but they should diligently perform respiratory and hand hygiene[39]. No evidence so far that babies have active coronavirus transmitted from mothers Low and Middle-Income Countries (LMICs) The link between mortality and health care resources in the COVID-19 pandemic may cause concerns for LMICs because[40]: Inability to afford large-scale diagnostics. ICU beds and personnel trained in critical care may be limited. Inability to fund the additional cost of critical care units from limited health budgets. Disruption of supply chains and depletion of stock, such as medical supplies, equipment and PPE. High numbers of internally displaced people and displace refugees who often have co-morbidities and reside in large-scale camps[41]. Resources Physiotherapy Member Organisation by Country: Best Practices for Coronavirus World Physiotherapy list of links to various global organisations and resources Governmental Information for Health Professionals UK Australia CDC (US) WHO Free Online Coursework via WHO United Nations European Centre for Disease Prevention and Control Overview Resources and Factsheets CDC Evidence Relevant to Critical Care (Cochrane) Infection Control Respiratory Hygiene (CDC) The Lancet COVID-19 Resource Center Online course offered through Imperial College London Johns Hopkins University & Medicine Coronavirus Resource Center JAMA network Coronavirus Disease 2019 (COVID-19) – research articles related to the pandemic Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR) Link to a real-time map of global cases by Johns Hopkins University This article explains it further.Respiratory Management of COVID 19 – PhysiopediaIntroduction This content has been generously supported by World Physiotherapy Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS-CoV-2), is a single-stranded ribonucleic acid (RNA) encapsulated corona virus and is highly contagious. Transmission is thought to be predominantly by droplet spread (i.e. relatively large particles that settle in the air), and direct contact with the patient, rather than ‘airborne spread’ (in which smaller particles remain in the air longer). There is still no specific antiviral treatment for COVID-19 infection, only supportive therapies including respiratory care for affected patients, especially in more severe cases. [1] Approximately 15% of individuals with COVID-19 develop moderate to severe disease and require hospitalisation and oxygen support, with a further 5% who require admission to an Intensive Care Unit and supportive therapies including intubation and ventilation.[2] The most common complication in severe COVID-19 patients is severe pneumonia, but other complications may include Acute Respiratory Distress Syndrome (ARDS), Sepsis and Septic Shock, Multiple Organ Failure, including Acute Kidney Injury and Cardiac Injury, which are more prevalent in at-risk groups including Older Age (> 70 years) and those with Co-morbid Diseases such as Cardiovascular Disease, Lung Disease, Diabetes and those who are Immunosuppressed[2]. In a small proportion of these, the illness may be severe enough to lead to death. Data currently suggests that illness is less common and usually less severe in younger adults. [3] Many patients presenting with COVID-19 will have no specific airway clearance needs. It is important that staff contact is kept to a minimum with positive patients to help reduce the risk of transmission therefore follow usual on-call policies and criteria. To date, COVID-19 patients who require hospitalisation are presenting with pneumonia features and bilateral patchy shadows or ground-glass opacity in the lungs. There have been no reports of COVID-19 positive patients having high secretion loads that would require intensive respiratory physiotherapy/airway clearance. This may change as the situation evolves and for that reason, all presenting patients should be discussed with Consultant Respiratory Clinicians/Critical Care Consultants before mechanical devices are used and guidance from a physiotherapist’s specific Service Provider should be followed. It is important to note that some therapeutic interventions will be contraindicated for patients with COVID-19. There may be patients with existing respiratory conditions who require personalised physiotherapy treatments which may include mechanical airway clearance or oscillating devices. In this scenario, it is important that the risk and benefit of continuing with the regime are discussed with Consultant Respiratory Clinicians/Critical Care Consultants. [4] Clinical Syndromes The World Health Organisation outlines the following Clinical Syndromes associated with COVID-19: [2] Mild Illness Patients present with uncomplicated upper respiratory tract viral infection and may have non-specific symptoms such as fever, fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or headache. Rarely. patients may also present with diarrhoea, nausea, and vomiting. The elderly and immunosuppressed may present with atypical symptoms. Symptoms due to physiologic adaptations of pregnancy or adverse pregnancy events, such as dyspnea, fever, GI-symptoms or fatigue, may overlap with COVID- 19 Symptoms. Pneumonia Adult: with pneumonia but no signs of severe pneumonia and no need for supplemental oxygen. Child: with non-severe pneumonia who has a cough or difficulty breathing + fast breathing: Fast Breathing (in breaths/min) .< 2 months old ≥ 60; 2-11 months old ≥ 50; and 1-5 years old ≥ 40, and no signs of severe pneumonia. Patients may be productive, with an increased sputum load but this is a less common presentation in viral pneumonia. Severe Pneumonia Adolescent or Adult: Fever or suspected respiratory infection, plus one of the following: High Respiratory Rate > 30 breaths/min; Severe Respiratory Distress; or SpO2 ≤ 93% on Room Air. Child: with a cough or difficulty in breathing, plus at least one of the following: Central Cyanosis or SpO2 < 90%; Severe Respiratory Distress (e.g. Grunting, Very Severe Chest Indrawing); Signs of Pneumonia with a general danger sign: Inability to breastfeed or drink, Lethargy or Unconsciousness, or Convulsions. Other signs of pneumonia may be present: Chest Indrawing; Fast Breathing (in breaths/min): < 2 months: ≥ 60; 2 – 11 months: ≥ 50;1 – 5 years: ≥ 40. While the diagnosis is made on clinical grounds, chest imaging may identify or exclude some pulmonary complications. Acute Respiratory Distress Syndrome (ARDS) Onset: Within 5 – 7 days from the onset of initial respiratory symptoms Diagnostic Tools (Radiograph, CT Scan, or Lung Ultrasound): Bilateral Opacities, not fully explained by volume overload, lobar or lung collapse, or nodules; Origin of Pulmonary Infiltrates: Respiratory failure not fully explained by cardiac failure or fluid overload; Need Objective Assessment (e.g. Echocardiography) to exclude Hydrostatic cause of infiltrates/oedema if no risk factor present. Oxygenation Impairment in Adults: Based on PF Ratio, which is the ratio of arterial oxygen partial pressure to fractional inspired oxygen Mild ARDS: 200 mmHg < PaO2/FiO2a ≤ 300 mmHg (with PEEP or CPAP ≥ 5 cmH2O, Ornon-ventilated) Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤ 200 mmHg (with PEEP ≥ 5 cmH2O, or Non-ventilated) Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥ 5 cmH2O, or Non-ventilated) When PaO2 is not available, SpO2/FiO2 ≤ 315 suggests ARDS (including in Non-ventilated patients). Oxygenation Impairment in Children: Note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2. Use PaO2-based metric when available. If PaO2 not available, wean FiO2 to maintain SpO2 ≤ 97% to calculate OSI or SpO2/FiO2 ratio: Bilevel (NIV or CPAP) ≥ 5 cmH2O via full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤ 264 Mild ARDS (Invasively Ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5 Moderate ARDS (Invasively Ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3 Severe ARDS (Invasively Ventilated): OI ≥ 16 or OSI ≥ 12.3. Sepsis Adults: Life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection. Signs of organ dysfunction include: Altered Mental Status; Difficult or Fast Breathing; Low Oxygen Saturation; Reduced Urine Output; Fast Heart Rate; Weak Pulse; Cold Extremities; Low blood Pressure; Skin Mottling; Laboratory Evidence of Coagulopathy, Thrombocytopenia, Acidosis, High Lactate, or Hyperbilirubinemia. Children: Suspected or proven infection and ≥ 2 age-based systemic inflammatory response syndrome criteria, of which one must be abnormal temperature or white blood cell count. Septic Shock Adults: Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP MAP ≥ 65 mmHg and serum lactate level > 2 mmol/L. Children: Any hypotension (SBP < 5th centile or > 2 SD below normal for age) or two or three of the following: Altered Mental State; Tachycardia or Bradycardia – HR < 90 bpm or > 160 bpm in Infants or HR < 70 bpm or > 150 bpm in Children; Prolonged Capillary Refill (> 2 sec) or Feeble Pulse; Tachypnoea; Mottled or Cool Skin or Petechial or Purpuric Rash; Increased Lactate; Oliguria; Hyperthermia or Hypothermia Patients with severe disease often need oxygenation support. High-flow oxygen and noninvasive positive pressure ventilation have been used, but the safety of these measures is uncertain, and they should be considered aerosol-generating procedures that warrant specific isolation precautions and PPE considerations. Some patients may develop acute respiratory distress syndrome and warrant intubation with mechanical ventilation; extracorporeal membrane oxygenation may be indicated in patients with refractory hypoxia. Physiotherapy may be beneficial in the respiratory treatment and physical rehabilitation of patients with COVID-19, although a productive cough is a less common symptom, physiotherapy may be indicated if patients with COVID-19 present with airway secretions that they are unable to independently clear. This may be evaluated on a case- by-case basis and interventions applied based on clinical indicators, and may also be utilised in high risk individuals e.g. patients with existing comorbidities that may be associated with hypersecretion or ineffective cough (e.g. neuromuscular disease, respiratory disease, cystic fibrosis etc). [5] Guideline Recommendations: Senior physiotherapists should be involved in determining the appropriateness of physiotherapy interventions for patients with suspected and/or proven COVID-19 in consultation with senior medical staff and according to a referral guideline. [5] Physiotherapy will have a strong role in providing exercise, mobilisation and rehabilitation interventions to survivors of critical illness myopathies associated with COVID-19 in order to enable a functional return to home. [5] Procedures at Risk of Contamination COVID-19 is spread by inhalation of infected matter containing live virus, which can travel up to 2m or by exposure from contaminated surfaces. SARS-CoV-2 remains viable for at least 24 hours on hard surfaces and up to eight hours on soft surfaces. Aerosol airborne infected particles created during a sneeze or cough remain viable in the air for at least three hours. [5] Aerosol-generating procedures create an increased risk of transmission of infection. 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.[3][5] Aerosol Generating Procedures (AGP) Aerosols generated by medical procedures are one route for the transmission of the COVID-19 virus. For patients with suspected/confirmed COVID-19, any of these potentially infectious AGPs should only be carried out when essential and minimised as much as possible. Where these procedures are indicated, they should be carried out in a single room with the doors shut but preferably should be completed in a Negative Pressure Side Room. Only those healthcare staff who are needed to undertake the procedure should be present. Full PPE Equipment including a disposable, Fluid Repellent Surgical Gown, Gloves, Eye Protection and an FFP3 Respirator Mask should be worn by those undertaking the procedure and those in the room and good hand hygiene following the procedure. Hair cover should also be considered. The following procedures are considered to be potentially infectious AGPs: [3] Intubation, Extubation and Related Procedures; Tracheotomy/Tracheostomy Procedures; Manual Ventilation; Open Suctioning; Bronchoscopy; Non-Invasive Ventilation (NIV) e.g. Bi-level Positive Airway Pressure (BiPAP)and Continuous Positive Airway Pressure Ventilation (CPAP); Surgery and Post-Mortem Procedures in which high-speed devices are used; High-Frequency Oscillating Ventilation (HFOV); High-flow Nasal Oxygen (HFNO) Induction of Sputum; Note: Induction of sputum typically involves administration of nebulised saline to moisten and loosen respiratory secretions (this may be accompanied by chest physiotherapy such as percussion and vibration to induce forceful coughing). This may be required if lower respiratory tract samples are needed Certain other procedures/equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk. Procedures in this category include: [3] Administration of Pressurised Humidified Oxygen; Administration of Medication via Nebulisation; Note: During nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces (combines) with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks. Physiotherapy Specific Aerosol Generating Techniques [3] 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), Mechanical Insufflation-Exsufflation (Cough Assist) Devices, Intra/Extra Pulmonary High Frequency Oscillation Devices (e.g. the Vest / MetaNeb / Percussionaire etc.) Any Mobilisation or Therapy that may result in Coughing and Expectoration of Mucus Any Diagnostic Interventions that involve use of Video Laryngoscopy that can result in Airway Irritation and Coughing (e.g. Direct Visualisation during airway clearance techniques or when assisting Speech and Language Therapists perform Fibreoptic Endoscopic Evaluation of Swallow) Decontamination Reusable (communal) non-invasive equipment must be decontaminated: between each patient and after patient use; after blood and body fluid contamination; and at regular intervals as part of equipment cleaning. An increased frequency of decontamination should be considered for reusable non-invasive care equipment when used in isolation/cohort areas. [3] Equipment Reusable equipment should be avoided if possible; if used, it should be decontaminated according to the manufacturer’s instructions before removal from the room. If it is not possible to leave equipment inside a room then follow IPC Guidelines on Decontamination. This usually involves cleaning with neutral detergent, then a chlorine-based disinfectant, in the form of a solution at a minimum strength of 1,000ppm available chlorine (e.g. “Haz-Tab” or other brands). If possible use dedicated equipment in the isolation room. Avoid storing any extraneous equipment in the patient’s room Dispose of single-use equipment as per clinical waste policy inside a room Point of care tests, including blood gas analysis, should be avoided unless a local risk assessment has been completed and shows it can be undertaken safely Ventilators and mechanical devices (e.g. Cough Assist Machines) should be protected with a high-efficiency viral-bacterial filter such as BS EN 13328-1. When using mechanical airway clearance, filters should be placed at the machine end and the mask end before any expiratory or exhalation ports. Filters should be changed when visibly soiled or dependent on the filter used either after each use or every 24 hours. Complete circuit changes should be undertaken every 72 hours (please follow specific Service Provider guidance on this) Closed system suction should be used if patients are intubated or have tracheostomies Disconnecting a patient from mechanical ventilation should be avoided at all costs but if required the ventilator should be placed on standby Manual hyperinflation (bagging) should be avoided if possible and attempt ventilator recruitment manoeuvres where possible and required Water humidification should be avoided and a heat and moisture exchanger should be used in ventilator circuits Disposable crockery and cutlery may be used in the patient’s room as far as possible to minimise the numbers of items which need to be decontaminated Any additional items such as Stethoscopes, Pulse Oximeters or Ultrasound Probes that are taken into a room will also need to be disinfected, regardless of whether there has been direct contact with the patient or not. This is due to the risk of environmental contamination of the equipment within the isolation room. [3] Patients Rooms If AGPs are undertaken in the patient’s own room, the room should be decontaminated 20 minutes after the procedure has ended (please follow specific Service Provider IPC guidance on this also). If a different room is used for a procedure it should be left for 20 minutes, then cleaned and disinfected before being put back into use. Clearance of any aerosols is dependent on the ventilation of the room. In hospitals, rooms commonly have 12 to 15 air changes per hour, and so after about 20 minutes, there would be less than 1 per cent of the starting level (assuming cessation of aerosol generation). If it is known locally that the design or construction of a room may not be typical for a clinical space, or that there are fewer air changes per hour, then the local IPCT would advise on how long to leave a room before decontamination. [3] Oxygen Therapy In the mild and moderate stages of disease, normal oxygen supportive measures (facemask oxygen) may be advantageous. WHO [2] recommends supplemental oxygen therapy immediately for patients with respiratory distress, hypoxaemia or shock with a target SpO2 > 94%. Patients may continue to have increased work of breathing or hypoxemia even when oxygen is delivered via a face mask with reservoir bag (flow rates of 10 – 15 L/min, which is typically the minimum flow required to maintain bag inflation; FiO2 0.60 – 0.95). [2] Nasal cannulas are not recommended as they may cause a higher spread of droplets.[6] Early recognition and referral of patients with worsening respiratory function while on conventional oxygen therapies, such as simple face masks or masks with reservoir bags, are important to ensure the timely and safe escalation of respiratory support. Early optimisation of care and involvement of Intensive Care Unit is recommended. In patients with COVID-19 there is the potential for a worsening of hypoxia and an increased need for intubation and invasive mechanical ventilation so close monitoring is advised.[7] Oxygen therapy targets may vary depending on the presentation of the patient.[5] For patients with presenting with severe respiratory distress, hypoxaemia or shock SpO2 > 94% is targeted [2] Once a patient is stable SpO2 > 90% [2] in non-pregnant adults and 92-95% [8] in pregnant adults are targeted. In adults with COVID-19 and Acute Hypoxaemic Respiratory Failure SpO2 target should not be maintained higher than 96% [9] High Flow Nasal Oxygen (HFNO) There have been some differing opinions on the use of HFNO due as an aerosol generating procedure but based on the Italian experience, HFNO has been found to be beneficial at the early stage, with a select cohort of patients who present with hypoxemic respiratory failure with no evidence of hypercapnia and can prevent intubation in some patients. [1] Given that HFNO is an aerosol generating procedure negative pressure rooms are preferable for patients receiving HFNO therapy and all staff entering the room should wear optimal PPE Equipment including a disposable, fluid repellent surgical gown, gloves, eye protection and an FFP3 respirator mask to ensure a low risk of airborne transmission. Flow rates of up to 60% and 100% oxygen are possible with HFNO. [10][1] Early recognition and referral of patients with worsening respiratory function (hypercapnia, acidaemia, respiratory fatigue), haemodynamic instability or those with altered mental status are important to ensure the timely and safe escalation of respiratory support, with consideration for early invasive mechanical ventilation if appropriate.[11][1] Guideline Recommendations: While HFNO does carry a small risk of aerosol generation, it is considered a recommended therapy for hypoxia associated with COVID-19, as long as staff are wearing optimal airborne PPE. The risk of airborne transmission to staff is low when optimal PPE and other infection control precautions are being used. Negative pressure rooms are preferable for patients receiving HFNO. [5] Ventilatory Support Acute or chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes. Non-Invasive Ventilation (CPAP/NIV) Routine use of non-invasive ventilation is not recommended. Non-invasive ventilation, an aerosol generating procedure, is when oxygen is given as breathing support by using a face mask or nasal mask under positive pressure, and is a recognised evidence-based intervention utilised for the treatment of hypercapnic respiratory failure. The amount of pressure generally alternates depending on inhalation or exhalation. Although non-invasive ventilation may temporarily improve oxygenation and reduce the work of breathing in patients with viral infections complicated by pneumonia, this method does not necessarily change the natural disease course and as such non-invasive ventilation is not routinely recommended and has no role in severe hypoxemic respiratory failure. Where non-invasive ventilation is utilised, a clear plan for treatment failure and escalation of care should be in place. [11] Current experience suggests that non-invasive ventilation for COVID-19 can be associated with a high failure rate, delayed intubation and possibly increased risk of aerosolisation with poor mask fit.[12][11] It seems clear from the available evidence that non-invasive ventilation should not be routinely used when the patient has severe respiratory failure or a trajectory that suggests that invasive ventilation is inevitable. In such circumstances, deteriorating patients should be considered for early endotracheal intubation and transitioned from oxygen therapy via a simple facemask to invasive ventilation without delay. [11][13] Negative prognostic factors for non-invasive ventilation success are overall severity, renal failure and hemodynamic instability.[1] Non-invasive ventilation has been considered an effective strategy with a specific cohort of patients in the early presentation of COVID-19, in particular with presentations of COVID-19 with hypercapnic respiratory failure, such as those with concomitant respiratory conditions e.g. COPD.[1] In Italy, where non-invasive ventilation has been utilised with this cohort group, they recommend to perform a single attempt of up to 1 hour.  If substantial improvement does not occur, the medical team must be alerted because the patient should be considered for early endotracheal intubation and invasive ventilation within a controlled environment with adequate infection prevention and control measures taken. [10] In order for non-invasive ventilation to be delivered in a safe manner and minimise the risk of aerosolisation, negative pressure single rooms should be used, using a dual link system with separate expiatory port or use of a double port filter system with a viral filter placed between the mask and the respiratory port. Recommendations in terms of non-invasive ventilation preferences are; First Choice: CPAP without humidification and with Hood / Helmet PEEP between 10 – 12 cmH20 and up to 15-20 cmH2O according to patient’s needs, tolerance and any side-effects. Second Choice: CPAP with mask Third Choice: NIV with face mask (total full face mask / oronasal face mask with filter between mask respiratory port) Non-invasive ventilation can be used effectively to bridge extubation and can be used to support extubation in the intensive care unit. The following Standard Operating Protocol for the Setup and Use of Non-Invasive Ventilation or HiFlow Oxygen (AirVo) for Patients with Suspected or Confirmed Coronavirus Version 1.7 – March 17th, 2020 provides a detailed outline for HFNO & NIV use. [14] Guideline Recommendation: Routine use of NIV is not recommended. as current experience with COVID-19 hypoxic respiratory failure reflects a high associate failure rate. If utilised e.g. with a patient with COPD or post-extubation it must be provided with strict airborne PPE. [5] Invasive Ventilation Lung protective mechanical ventilation (MV) is the recommended strategy for the management of acute respiratory failure, which aims to protect the lung. This is when mechanical ventilation is employed with the use of a low tidal volume strategy (4-8ml/kg predicted body weight) and limiting plateau pressures to less than 30 cmH2O. Permissive hypercapnia is usually well-tolerated and may reduce volutrauma, local over distention of normal alveoli as achievement of adequate oxygenation is key. Higher levels of PEEP, greater than 15 cmH2O, are recommended. [11] Alternate modes of ventilation such as APRV may be considered based on clinician preference and local experience. Viral (rather than HME) filters should be utilised and circuits should be maintained for as long as allowable, as opposed to routine changes. [11] Generally patients are sedated to allow adequate control of ventilation. While good practice to perform daily sedation holds, patients with COVID-19 may be kept under deeper sedation until adequate oxygenation levels are achieved to reduce the risk of ventilator dyssynchrony and control respiratory drive (which is important to achieve adequate target tidal volumes). Use of neuromuscular blockade agents are not generally recommended, unless the patient has significant worsening hypoxia or hypercapnia and in situations where the patient’s respiratory drive cannot be managed with sedation alone resulting in ventilator dyssynchrony and lung decruitment. [2][11][12] Use of recruitment measures are not recommended in severe ARDS but may be considered during the weaning phase but in the case of COVID-19 patients, manual recruitment methods such as manual hyperinflation which involve a break in the circuit are not recommended due to increased risk of droplet spread. In the majority of patients with COVID-19, endotrachael tubes are used, with very few requiring tracheostomy. It is vital that cuffs are inflated at all times and never deflated during any treatments. If tracheostomy is indicated subglotic tracheotomy should be utilised so above cuff vocalisation can be achieved without needing to deflate the cuff to improve communication and swallow. Guideline Recommendation: Patients with worsening hypoxia, hypercapnia, acidaemia, respiratory fatigue, haemodynamic instability or those with altered mental status should be considered for early invasive mechanical ventilation if appropriate. The risk of aerosol transmission is reduced once a patient is intubated with a closed ventilator circuit. [5] Positioning Positioning is a vital component of management for the mechanically ventilated COVID-19 patient, with regular turning recommended to prevent atelectasis, optimise ventilation and prevent pressure sores. Positioning can include lateral (side lying) positioning but may also include prone positioning, which is well recognised to treat hypoxemic respiratory failure. Prone ventilation is ventilation that is delivered with the patient lying in the prone position. Prone ventilation may improve lung mechanics and gas exchange, thus improving oxygenation in the majority of patients with ARDS, and could improve outcomes. Current reports suggest prone ventilation is effective in improving hypoxia associated with COVID-19 and should be completed in the context of a hospital guideline that includes appropriate PPE for staff and that minimise the risk of any adverse events, e.g. accidental extubation and breaking of the circuit. [2][11] With adult patients, prone positioning is recommended for at least 16 hours per day[6]. View a set of pragmatic proning guidelines, from the American Journal of Respiratory and Critical Care Medicine[15]. [16] [17] Suctioning Closed inline suction catheters are recommended and imperative. Any disconnection of the patient from the ventilator should be avoided to prevent lung decruitment and aerosolisation. If necessary, the endotracheal tube should be clamped and the ventilator disabled (to prevent aerosolisation). [11] Suctioning is not required routinely but should be used as required. Nebulisation The use of nebulised agents (e.g. salbutamol, saline) for the treatment of non-intubated patients with COVID-19 is not recommended as it increases the risk of aerosolization and transmission of infection to health care workers in the immediate vicinity. The use of metered-dose inhalers are preferred where possible. [5][11] If a nebulizer is required and deemed essential, liaise with local guidelines for directions to minimise aerosolization e.g. use of a Pari sprint with inline viral filter with use of adequate airborne precautions and PPE. [5] Humidification Use of humidification, both cold and warm water, is not recommended and HME Filters should be used. [1][10] Weaning and Liberation from Mechanical Ventilation Standard weaning protocols should be followed. HFNO and/or NIV with well-fitted facemask with separate inspiratory and expiratory can be considered as bridging therapy post-extubation but must be provided with strict use of staff PPE. [11] Specific Physiotherapy Techniques[18] Physiotherapy is an important intervention that prevents and mitigates the adverse effects of prolonged bed rest and mechanical ventilation during critical illness. Rehabilitation delivered by the physiotherapist is tailored to patient needs and depends on the conscious state, psychological status and physical strength of the patient. It incorporates any active and passive therapy that promotes movement and includes mobilisation. Much of the role of the ICU physiotherapist will continue during the COVID-19 pandemic, with the main change in practice being the routine use of full PPE while working within the ICU environment. Acute Phase In the early stages of COVID-19 and respiratory distress, care is advised when planning a treatment programme. Common modalities often used by respiratory physiotherapists may be contraindicated in the acute phase as they may further compromise the increased work of breathing. Contraindicated interventions include:[19] Diaphragmatic breathing Pursed lips breathing Bronchial hygiene/lung re-expansion techniques (PEP Bottle, EzPAP®, cough machines, etc.) Incentive spirometry Manual mobilisation techniques or stretching of the rib cage Nasal washings Respiratory muscle training Exercise training Patient mobilisation during clinical instability Physiotherapists should continue to actively screen and/or accept referrals for mobilisation, exercise and rehabilitation. When screening, discussion with nursing staff, the patient (e.g. via phone) or family is recommended before deciding to enter the patient’s isolation room. For example,to try to minimise staff who come in to contact with patients with COVID-19, physiotherapists may screen to determine an appropriate aid to trial. A trial of the aid may then be performed by the nursing staff already in an isolation room, with guidance provided if needed by the physiotherapist who is outside the room.[5] Weaning Phase Where the patient is awake, cooperative and in the weaning stage, consider the use of the active cycle of breathing technique as well as lung volume recruitment procedures (e.g. breath stacking) combined with positioning to ensure the patient is involved in his/her treatment. Ventilator Disconnection Anything in relation to ventilator disconnection should not be utilised e.g. manual hyper inflation / bagging. Mechanical Insufflation-Exsufflation (Cough Assist) Devices Generally, cough assist devices are not indicated or required in viral pneumonia, as they do not tend to have productive chests, retained secretions or problems with secretion retention or mucus plugging. If it was felt that such a device was indicated, the issue must be discussed with the medical team considering the physiological impact of Insufflation-Exsufflation in someone who may already have an acute lung injury, which may be counterproductive to the lung protection strategy utilised. The use of this type of device may be considered in patients with co-morbid conditions where these techniques were part of their normal airway clearance strategies, but benefit versus risk would need to be discussed with the team. This is not recommended and would not be considered first line intervention. Because it is an AGP, full PPE would be required and in order to protect the machine and the patient, a double viral filter system should be in place at the mask and device expiratory port. Lung Ultrasound Diagnostic lung ultrasound has been identified as a potential diagnostic tool in the assessment and management of COVID-19. It shows similar findings to radiological cases and has a higher degree of accuracy than the bedside chest radiograph, with findings of multi-lobar distribution of B-lines and diffuse lung consolidation.[20][21][5][5] It approaches the level of accuracy seen with computed tomography (CT) for many pathologies that reach the pleura.[20] Lung ultrasound can be used throughout the course of the treatment process to track the evolution of the disease, to monitor lung recruitment manoeuvres, to provide feedback in relation to the success of interventions and to assist decision-making in relation to weaning and liberation from mechanical ventilation.[20] The following provides a practical guideline for the use of lung ultrasound during the COVID-19 Pandemic within an acute hospital setting: Physiotherapists use of Lung Ultrasound during the COVID-19 Pandemic – A Practical Guideline on Supporting Acute Hospital Colleagues. Manual Techniques There is controversy about the effectiveness of manual techniques in general. There is minimal evidence for percussion. There is some evidence for expiratory vibrations to mobilise secretions and manual assisted cough to improve cough effectiveness and aid mucocillary clearance if required. This could be an adjunct and safe to use with patients who are both mechanically ventilated and extubated provided adequate PPE is used. Rehabilitation Phase This is where we will see the main role of the physiotherapist in the management of the patient with COVID-19. There is strong evidence to suggest that early mobilisation with a focus on returning to functional activities helps in reducing the length of hospital stay and minimising functional decline, thus the sooner patients start mobilising, the sooner they can leave the ICU, and potentially have better long-term outcomes. This phase of management should incorporate a multi-disciplinary approach including measures to prevent avoidable physical and non-physical morbidity, support adequate nutrition (particularly following the effects of prone ventilation) and an individualised, structured rehabilitation programme. This phase should follow the typical approach for rehabilitation and exercise within the Intensive Care Unit, followed by transfer to ward-based rehabilitation. Passive, Active Assisted, Active, or Resisted Joint Range of Motion Exercises to maintain or improve joint integrity and range of motion and muscle strength; [5] Mobilisation and Rehabilitation (e.g. bed mobility, sitting out of bed, sitting balance, sit to stand, walking, tilt table, standing hoists, upper limb or lower limb ergometry, exercise programs). [5] Prevention of Complications Physiotherapists can play a key role in the prevention of a range of complications including ventilator-associated pneumonias, secondary infections, contractures or pressure areas/sores. Reduced Days of Mechanical Ventilation  Use weaning protocols or development of individual weaning plans  Assessment of spontaneous breathing capacity and readiness for extubation, including involvement in daily sedation holds and spontaneous breathing trials[2]. Reduce the Incidence of Ventilator-Associated Pneumonia It is really important to reduce this risk because any secondary infection will increase the number of days the patient is intubated and ventilated and thus their overall time in the ICU, taking up bed space for longer than should be required and reduce flow through the hospital. Keep the patient in a semi-sitting position (30 – 45 Degrees) Regular 2 hourly turning to minimise the risk of atelectasis and consolidation Prone ventilation where indicated and appropriate. In China & Italy they often had multiple patients proned within the ICU Use a closed suction system; periodically drain and discard condensate intubing Use a new ventilation circuit for each patient, once the patient is ventilated change the circuit only if it is damaged or soiled, not routinely Change heat moisture exchanger when it malfunctions, when soiled, or every 5-7 days[2] Assist in the extubuation phase, and weaning potential from invasive ventilation. Reduce the Incidence of Pressure Ulcers Turn the patient every 2 hours [2] Pressure care positioning / protection of pressure areas Reduce the Incidence of Intensive Care-Related Myopathy Early mobilisation is encouraged. Actively mobilise the patient as soon as their condition allows and when safe to do so. [2] Preventing Osteonecrosis of Femoral Head There is an increased risk of steroid-induced osteonecrosis of the femoral head (ONFH). Research suggests follow-up MRI after discharge to detect ONFH and Physical therapy with pharmacotherapy to be prescribed for patients with early-stage steroid-induced ONFH[22]. Indications for Physiotherapy Referral The following guidelines outline the relevant indications for physiotherapy in the presence of a suspected or confirmed case of COVID-19. [5] Airway Clearance COVID-19 Patient Presentation (Confirmed or Suspected) Physiotherapy Referral ? Mild symptoms without significant respiratory compromise  e.g. fevers, dry cough, no chest x-ray changes. Physiotherapy interventions are not indicated for airway clearance or sputum samples No physiotherapy contact with patient. Pneumonia presenting with features: Low-level oxygen requirement (e.g. oxygen flow ≤5L/min for SpO2 ≥ 90%). Non-productive cough; Patient coughing and able to clear secretions independently. Physiotherapy interventions are not indicated for airway clearance or sputum samples. No physiotherapy contact with patient. Mild symptoms and/or pneumonia AND co-existing Respiratory or Neuromuscular Comorbidity e.g. Cystic Fibrosis, neuromuscular disease, spinal cord injury, bronchiectasis, COPD, AND current or anticipated difficulties with secretion clearance Physiotherapy referral for airway clearance. Staff use airborne precautions. Where possible, patients should wear a surgical mask during any physiotherapy. Mild symptoms and/or pneumonia AND evidence of exudative consolidation with difficulty clearing or inability to clear secretions independently e.g. weak, ineffective and moist sounding cough, tactile fremitus on chest wall, moist/wet sounding voice, audible transmitted sounds. Physiotherapy referral for airway clearance. Staff use airborne precautions. Where possible, patients should wear a surgical mask during any physiotherapy. Severe symptoms suggestive of pneumonia / lower respiratory tract infection e.g. increasing oxygen requirements, fever, difficulty breathing, frequent, severe or productive coughing episodes, Chest X-ray / CT / Lung Ultrasound changes consistent with Consolidation. Consider physiotherapy referral for airway clearance. Physiotherapy may be indicated, particularly if weak cough, productive and/or evidence of pneumonia on imaging and/or secretion retention. Staff use airborne precautions. Where possible, patients should wear a surgical mask during any physiotherapy. Early optimisation of care and involvement of ICU is recommended. Mobilisation, Exercise & Rehabilitation COVID-19 Patient Presentation (Confirmed or Suspected) Physiotherapy Referral ? Any patient at significant risk of developing or with evidence of significant functional limitations e.g. patients who are frail or have multiple comorbidities impacting on their independence e.g. mobilisation, exercise and rehabilitation in ICU patients with significant functional decline and/or (at risk for) ICU-acquired weakness Physiotherapy referral. Use droplet precautions. Use airborne precautions if close contact required or possible AGPs. If not ventilated, patients should wear a surgical mask during any physiotherapy whenever possible. On-Call Physiotherapy Considerations Acutely unwell confirmed or suspected COVID-19 patients should NOT be routinely referred to physiotherapy. There are currently no reports that suggest COVID-19 patients have high secretion loads requiring intensive respiratory physiotherapy/airway clearance. Physiotherapy intervention is likely to be of limited benefit in the acute stages and most beneficial use of physiotherapy resources will be to facilitate the treatment and discharge of non-infected patients as well as training and supporting our colleagues in managing the acutely unwell. Physiotherapists will have a role in the rehabilitation of COVID-19 patients who have not returned to their functional baseline once they are no longer acutely unwell. [4] The WHO recommends limiting the number of Health Care Workers who are in contact with a suspected and confirmed COVID-19 patients and to limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. [2] Physiotherapy referrals should only be made for patients that meet the On-Call Physiotherapy Criteria, which normally would include; [4] Inclusion Criteria: Patients likely to benefit from on-call physiotherapy: An increase in oxygen therapy to FiO2 >60% Evidence of retained pulmonary secretions with difficulty expectorating Ineffective cough/airway clearance Exclusion Criteria: Patient unlikely to benefit from on-call physiotherapy: Viral Pneumonia ARDS Cardiovascular Instability Uncooperative Patient Unstable Intracranial Pressure Uncontrolled Bronchospasm Pulmonary Embolism Non-acute COPD Criteria not appropriate for emergency call-out: Patients with a diagnosis of COVID-19 with a dry unproductive cough Patients with a diagnosis of COVID-19 with severe hypoxaemia requiring intubation Routine respiratory patients e.g. post-operatively, unless the criteria above are met Patients who are requiring suction only – If the patient requires suction ONLY, consider as a nursing technique. Mobilise any patient who is well enough as this is the most natural way of encouraging optimal pulmonary function. Such a patient is unlikely to require emergency physiotherapy. Resources Physiotherapy Specific Physiotherapy Specific Guidelines for the Acute Hospital Setting Physiotherapy Management for COVID-19 in the Acute Hospital Setting: Recommendations to Guide Clinical Practice. Version 1 23 March 2020 Rachael Moses, Consultant Respiratory Physiotherapist at Lancashire Teaching Hospitals. COVID-19: Respiratory Physiotherapy Management Information and Guidance. Version 1 Dated 15th March 2020 COVID-19 Respiratory Physiotherapy On Call Information and Guidance. Version 2 Dated 14th March 2020 COVID 19 and Respiratory Physiotherapy Referral Guideline. Version 1 Dated 18th March 2020 Adam Rochester, NIV Lead for Respiratory Support Services. Royal Brompton and Harefield NHS Trust. Standard Operating Protocol for the Setup and Use of Non-Invasive Ventilation or HiFlow Oxygen (AirVo) for Patients with Suspected or Confirmed Coronavirus. Version 1.7 Dated March 17th, 2020 Italian Association of Respiratory Physiotherapists (ARIR) Respiratory Physiotherapy in patients with COVID-19 Infection in Acute Setting David McWilliams, Consultant Physiotherapist, University Hospitals Birmingham NHS Foundation Trust COVID-19 Early Experiences from a Physiotherapy Perspective Kelly Morris, Isobel Hinton, Laura Mylott, Rachel Farley, Hannah Mitchell & Hannah Cumming, Physiotherapy Team, Guy’s and St.Thomas’ NHS Foundation Trust COVID-19 Physiotherapy Experience at Guy’s and St.Thomas’ Hospital British Thoracic Society BTS Advice for Community Respiratory Services in Relation to COVID19 Version 1 Dated 16th March 2020 Airway Management Guideline World Health Organisation Clinical Management of Severe Acute Respiratory Infection when Novel Coronavirus (nCoV) Infection is Suspected Interim Guidance Dated 28th January 2020 Australian and New Zealand Intensive Care Society The Australian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines Version 1 Dated 16th March 2020 Italian Thoracic Society (AIPO – ITS) and Italian Respiratory Society (SIP/IRS) Managing the Respiratory Care of patients with COVID-19 Version 1 Dated 8th March 2020 British Thoracic Society Use of Acute NIV in Patients Hospitalised with Suspected or Confirmed COVID-19 Infection Version 1 Dated 16th March 2020 Proning Guidelines The Faculty of Intensive Care Medicine Guidance For: Prone Positioning in Adult Critical Care Evidence Based Resources The First A�liated Hospital, Zhejiang University School of Medicine Handbook of COVID-19 Preventionand Treatment Cochrane Special Collections Coronavirus (COVID-19): Evidence Relevant to Critical Care British Medical Journal Coronavirus (COVID-19): Latest News and ResourcesCOVID-19: Shorter Term Health Considerations – PhysiopediaIntroduction The demands placed on the front line workers in relation to the COVID-19 pandemic have been described elsewhere and their efforts continue to inspire awe and gratitude around the globe. At the same time, health care professionals who do not work on the front line might be wondering “what can I do to help?” as well as, perhaps in the background, “how might this change my practice in the longer term?” Considering that some estimates project that the pandemic will occur in waves and that a vaccine is still 18 months away, we are still in the relatively early days so the full breadth and depth of the impacts will only be known after the fact. For now, the following considerations are based on information available about the current pandemic as well as similar historical situations (e.g. the SARS outbreak in 2003). Mental Health Stress disorders are associated with public health emergencies.[1] Assessment and treatment of such disorders in patients already in medical isolation wards is a challenge because mental health professionals may be considered non-essential in that context and therefore unauthorized to enter those wards. The front line professionals who can enter would therefore be responsible for addressing mental health as well (assuming the patient is physically well enough to be evaluated).[1] For patients with symptoms of COVID-19 who are self-isolating at home because they are not critically ill but feel they are in need of mental health support, mental health care professionals would have to determine if the requested service was considered “essential” at that moment. The definition of “essential” may vary between jurisdictions. From a Canadian perspective, “[a]ll non-essential and elective services should be ceased or reduced to minimal levels…Allowable exceptions can be made for time sensitive circumstance to avert or avoid negative patient outcomes or to avert or avoid a situation that would have a direct impact on the safety of patients.”[2] If not essential, the HCP would be authorized by their respective regulatory college to inform the patient of this determination and delay evaluation/intervention until an appropriate time. If the service was considered essential, the HCP would have to consider what would be the safest way to provide care. Given the reported shortage of PPE available and that community-based HCPs may be inundated with referrals (even before the pandemic started), tele- or video-conferencing may be the most appropriate and efficient option. HCPs would have to consider appropriate security for any online tools they use and also if they are still covered by liability insurance when providing care in this format.[3] In addition, if a patient was already under an HCP’s care but moved to a different jurisdiction in response to the pandemic, the HCP would have to consider if they are still authorized to care for that patient under the regulatory college of the new jurisdiction. Regulatory colleges may allow temporary approval given the extenuating circumstance but HCPs should contact the college to determine this.[4] Patients or people in general who are experiencing symptoms of mental stress could also access various types of self-directed online health education services, apps and videos that are available (e.g. TikTok, Youtube, Curable for pain management, Headspace for mindfulness training).[5] (Liu 2020) Because these require an internet connection as well as an appropriate device, access might be limited for some people (Yang 2020). As well, some services have a monetary cost which again might prevent access by those with lower income (especially given that many people in non-essential lines of work are unable to work because of isolation guidelines). Some resources have been made freely available in recognition of the difficult situation many people are finding themselves in as a result of the pandemic (e.g.Headspace, Curable). Front Line Health Care Workers Front line workers may also suffer from stress disorders given the demands placed upon them. Lai et al (2020) found a high prevalence of mental health symptoms among health care workers who were treating patients with COVID-19 in China.[6] Analysis of the self-report questionnaires indicated 50.4% of respondents had symptoms of depression, 44.6% had symptoms of anxiety, 34.0% had symptoms of insomnia and 71.5% had symptoms of distress. Women reported more severe symptoms of depression which the authors note may be because a high percentage of respondents were female nurses who are likely exposed to a higher risk of infection because of their close frequent contact with patients and also because they are working more hours than usual. Chen et al (2020) reported that in response to the escalating novel coronavirus public health event in China, a psychological intervention plan was developed which covered three areas: building a psychological intervention medical team (to provide online courses relating to common psychological problems), a psychological assistance hotline team (to provide guidance and supervision to solve psychological problems) and psychological interventions (e.g. various stress-relieving group activities).[7] Medical staff were reportedly reluctant to participate in the interventions despite exhibiting signs of psychological distress. As a result of an interview with staff, several issues were identified; getting infected themselves was not an immediate worry once staff started a shift but there were afraid of bringing the virus home to their families they did not know how to deal with uncooperative patients they worried about the shortage of PPE they worried about feeling incapable when caring for critically ill patients. The same members of staff reported that they did not need psychological intervention but that what would be of benefit was; more uninterrupted rest sufficient PPE supplies training in psychological skills to assist patients with anxiety, panic, etc mental health professionals to intervene when required. As a result, the hospital implemented the following; provision of a place of rest for over 100 staff members so they could temporarily isolate themselves from their families guarantee of food and daily living supplies video recording of staff in their work routines to share with families to alleviate their concerns change to pre-job training to include identification of and response to psychological problems sending security staff to help with uncooperative patients provision of detailed rules on use and management of PPE arrangement of leisure activities and training on how to relax effectively provision of psychological counsellors to provide support while in the rest area. Other Aspects of Health People may avoid hospitals or other health facilities because of the pandemic even though they have a condition that requires attention (whether or not it is a known or diagnosed condition) and in so avoiding, may harm themselves. During the SARS outbreak, it was estimated that four times as many Ontarians would die from lack of medical attention caused by the outbreak than would die from SARS itself.[8] People who were already receiving treatment but cannot at present due to social distancing requirements and/or closure of the facilities may suffer unless adequate alternatives can be arranged. In addition, Viswanath and Monga (2020) note that there is a concern regarding corticosteroid injections during a pandemic because they may depress the immune system while NSAIDs have been linked with more severe COVID-19 (e.g. prolonged illness and more severe respiratory or cardiac complications).[9] Paracetamol/acetaminophen are instead recommended to treat musculoskeletal pain in those with COVID-19.[9] Some ongoing method of pain management is critical. Eysenbach (2003) noted that during the SARS outbreak, Singapore General Hospital introduced a webcam-based physiotherapy program.[8] Almost 20 years on, more advanced and more widely available technology are making this option more feasible (although again, access on the end of the patient might be limited by financial or technological circumstances). Some providers are providing tele- and video-conferencing options for their patients. As with mental health services, an HCP may be authorized to provide in-person care if it is considered essential (e.g. post-surgical rehabilitation) provided guidelines for IPC etc are followed.[2] Self-Care Elias, Shen and Bar-Yam (2020) state that attention to self-care and wellness during the mild stage of COVID-19 may impact the probability and degree of severity.[10] Means of strengthening the immune response include elevated hydration, balanced nutrition, appropriate sleep and non-interference with a fever unless it exceeds safe limits. The authors make the following recommendations (noting that the recommendations are safe for those with reasonable general health while those with pre-existing health concerns might want to consult a physician first);[10] aerobic exercise – to strengthen the cardiovascular system before an infection might occur. If already infected but it is in the mild stage, moderate daily exercise can improve lung ventilation and may also benefit immune system. Ideally exercise should occur outdoors or in a well-ventilated area. keep windows open when possible to bring in more oxygen while letting viral particles exit, thus reducing the risk to others in that environment but also reducing re-exposure of the patient to viral particles which could affect pulmonary tissue that has not yet been infected or has been cleared by the immune system. clean surfaces and washing clothing/bedding – to protect non-infected people within the household and again to reduce the risk of re-exposure spend time outdoors – for the same reasons breathe in through the nose rather than the mouth – to allow cilia and mucous membranes to clean the incoming air perform deep breathing exercises multiple times per day – to bring in fresh air, improve lung capacity and expel viral particles from more stagnant areas of the lung additional lung health practices (the authors refer readers here) Education If working is not an option at present, physiotherapists and other HCPs could use this opportunity to educate themselves, either regarding COVID-19 or in other areas that would be of benefit to their patients and/or their practice, using some of the resources available online such as Physiopedia Plus. Stimulating, purposeful, educational challenges may be a way to assist or improve mental health at a tumultuous time. More General Ways to Help In addition to ways physiotherapists can help in this situation based on their profession, there are also ways to help that are an option for all people. stay at home except for essential work or errands (e.g. grocery shopping) adhere to social distancing guidelines when you do have to go out practise proper hand hygiene check that neighbours, friends and relatives are doing well don’t hoard food (everyone else needs to eat too!) donate to organizations that are assisting front line workers or that might be struggling just now because of everyone self-isolating (e.g. food banks, community shelters)Coronavirus (COVID-19) Course – PhysiopediaThis course has been generously supported by World Physiotherapy This course is currently available as a free open online course. It has been developed in response to this new virus being declared a pandemic by the World Health Organisation. The course has been updated according to emerging new information and is available for you to do at any time in Physioplus, it can be started and completed at any time that suits you. Go to the course on Physioplus Contents 1 Course Information 2 Quick Overview 3 Introduction 4 Aim 5 Intended Audience 6 Learning Objectives 7 Course Structure 8 Course Outline 9 Types of Learning Activity Involved 10 Cost 11 Where 12 Time Commitment 13 Language 14 Accreditation, Assessment and Certification 15 Thanks! 16 Still Have Questions? Course Information Course Type – Free, Open, Online Course Co-ordinators – Rachael Lowe Institution – Physiopedia About this course – This online course will develop knowledge Coronavirus (COVID-19) and the related role of the physiotherapist. Who can take part- This course is aimed at physiotherapy and physical therapy professionals, clinicians, students and assistants; other interested health care professionals interested in this subject are more than welcome to participate.  Date of course – 15th March 2020 – 31st December 2020 Time commitment- 8 hours Language – the course will be in English Requirements;- You will complete online learning activities, engage with additional resources, take part in the conversation online and complete the course evaluation. Assessment – There will be a final quiz. Awards – Physioplus completion certificate and CPD points. Quick Overview On Monday 16 March 2020 the course was released via social media platforms and Physiospot. The course will be available through our online learning platform – Physioplus. The full Coronavirus Disease MOOC course title is “Coronavirus Disease Programme” This programme is divided into four short courses, each being approximately 8 hours in length. Starting Monday 16 March 2020, the four courses were released simultaneously. You will get a certificate for each course completed. Once you have completed all four courses, if you are a full Physioplus member you will be able to submit an assignment to complete the full programme and receive the full programme certificate. The course will be available to complete for free until 31st December 2020. After this date full Physioplus members will be able to complete the full programme and refer back to any of the resources at any time in the future. The information page for this programme of courses can be viewed on Physioplus – Coronavirus Disease Programme Introduction We are currently living through an unprecedented global health crisis resulting from a pandemic caused by a novel Coronavirus. Many of the elderly, vulnerable and also our fellow frontline healthcare workers will bear the brunt of this crisis, however, the physiotherapy/physical therapy profession also has an important role to play. This series of online courses will explore the nature of this outbreak and how we can play our part in mitigating this crisis. Coronaviruses are a family of viruses that cause illnesses such as respiratory or gastrointestinal diseases. In January 2020 a previously unknown coronavirus was identified in Wuhan China. It mainly presents with respiratory symptoms, fever and can result in severe acute respiratory distress in high-risk populations. One of the early messages to emerge was the importance of implementing procedures and techniques for infection prevention, to limit healthcare-acquired infections as well as control the general spread of epidemics and pandemics. A key component of this is basic hand hygiene which forms the foundation of infection control. The use of personal protective equipment (PPE) such as gloves, masks, gowns and goggles allows healthcare personal to treat patients with communicable diseases while protecting themselves and others. The procedures for putting on (donning) and taking off (doffing) of PPE needs to follow specific sequencing and techniques in order to ensure best infection control and prevention practices. Due to the respiratory nature of the virus, this course will provide an overview of the role of the physiotherapist in the management of patients with COVID-19 in the acute hospital setting and also in the rehabilitation following recovery from the disease. This is an important aspect of management in individuals with COVID-19 as approximately 15% of diagnosed patients will develop moderate to severe disease and require hospitalisation and oxygen support, with a further 5% who require admission to an Intensive Care Unit and supportive therapies including intubation and ventilation. The most common complication in severe COVID-19 patients is severe pneumonia, but other complications may include Acute Respiratory Distress Syndrome (ARDS), Sepsis and Septic Shock, Multiple Organ Failure, including Acute Kidney Injury and Cardiac Injury. Aim This course aims to provide an introductory insight into this novel coronavirus and includes its clinical presentation, diagnosis, management and the prevention of transmission. Including advice on infection prevention and control and specifically reviews procedures and policies for hand hygiene and personal protective equipment. It also explains the role physiotherapists play in managing issues related to the COVID-19 disease from case identification, limiting transmission in different clinical settings, including an acute hospital setting, and treating patients with mild, moderate and severe symptoms. Intended Audience This course is aimed at physiotherapy and physical therapy professionals, clinicians, students and assistants; other interested health care professionals interested in this subject are more than welcome to participate.  Learning Objectives Describe COVID-19 in terms of the virus strain, transmission, incubation period, and case definitions Correctly identify COVID-19 symptoms, high-risk populations, and reasons for emergency medical treatment Explain infectious disease in terms of direct and indirect transmission of microorganisms, susceptible persons, and standard precautions Identify strategies for environmental cleaning and disinfecting and the importance of proper hand hygiene Describe practices that will help to limit the transmission of COVID-19 Plan early identification strategies of COVID-19 in your clinical setting Understand self-isolating protocols that patients and families/carers can follow to reduce the transmission of COVID-19 Select appropriate physiotherapy interventions for patients with COVID-19 who have respiratory symptoms List the most common complication seen in hospitalised patients with COVID-19 Correctly identify the type of cough and sputum load in patients with COVID-19 Discuss which procedures are aerosol-generating and which precautions to take Describe non-invasive and invasive mechanical ventilation in terms of uses, settings, precautions, and preventing complications Identify when a patient with COVID-19 is appropriate for a respiratory physiotherapy referral Course Structure This course will be divided into 4 separate smaller courses. Each course can be done as a stand alone course and it is suggested (but not required) that each course be completed over the duration of approximately a week. Please note that no deadlines are applied and this programme of courses can be started and completed according to your own schedule. We expect the required elements of each course to take around 8 hours depending on your schedule and learning style. Additionally, there are many optional resources provided and if you choose to review these the course could take significantly longer to complete. It’s not going to be easy, we’ll expect you to work hard for your completion certificate! You won’t be sitting back and watching webinars, we’ll expect you to undertake reading tasks, complete quizzes, perform literature searches and other learning activities. You’ll need to reflect on your own experiences and make written contributions to the discussion forum. This forum is where we can learn from each other’s experiences and knowledge from all around the world! At the end of the course, when you have completed all of the required elements, you will be able to download a certificate of completion and 8 Physioplus points will be added to your personalised learning dashboard in Physioplus. Course Outline Section 1: Understanding Coronavirus Disease (COVID-19) Section 2: Infection Prevention and Control Section 3: Role of Physiotherapy in COVID-19 Section 4: Respiratory Management of People with COVID-19 Section 5: Optional Assignment (to complete the programme) Types of Learning Activity Involved Reading Physiopedia pages, journal articles, book chapters. Watching videos. Attempting quizzes. Participating in an international discussion forum. Cost This course was FREE when it first ran from March -Dec 2020! Where This is a completely online course which will take place in Physiopedia’s complimentary e-learning platform Physioplus. You will need need to set up a FREE trial account to access the course, you can do that here. The course will become available on the Physioplus site from 15 March 2020. Time Commitment Completing this course will involve approximately 8 hours of learning activities that can be completed online at any time that suits you. There are no specific times that you are required to be online. Language This course will be in English. Although participants will only require basic English skills (reading skills are more important than conversational skills). Participants will be encouraged to be respectful and empathetic to those for whom English is not their first language (e.g. in the discussion forum). Accreditation, Assessment and Certification The course will be accredited in Australia and South Africa. On the successful completion of this course, each participant will be provided with a Physioplus Certificate of Completion and Physioplus Points (our own Physioplus points which are equivalent to CPD Points/CEUs). These will be awarded provided you: Be part of the Physiopedia Plus Community Culture. Log as completed all the required learning activities. Actively and appropriately participate in the course discussions. Pass a final quiz with a score of 80% or more. Complete a course evaluation form. Thanks! We would like to extend a massive thank you to the donation from World Physiotherapy that has contributed towards the funding for this course. Still Have Questions? You may find the answer here! Go to the course on Physioplus Retrieved from “” Category: MOOCsCOVID-19: Post-Acute Rehabilitation – PhysiopediaIntroduction Countries all across the world are in various stages of the pandemic with many countries now entering the “day after” COVID-19 phase. Many people who have suffered from the effects of this disease might now be at risk of long-term impairment and disability.[1] The extent of this impairment and disability is yet unknown, but it is clear from early research that these patients will be in need of rehabilitation in all phases of the disease – acute, post-acute and long-term. Rehabilitation is defined as “a set of interventions designed to reduce disability and optimize functioning in individuals with health conditions in interaction with their environment.”[2] Rehabilitation might very well be a key strategy to reduce the impact of COVID-19 on the health and function of people. Physiotherapists are essential to these rehabilitation efforts in all phases to facilitate early discharge, but even more to support and empower patients. Benefits of Rehabilitation in COVID-19 Patients Rehabilitation has a positive effect on health outcomes of patients with severe COVID-19. It achieves this through[3]: Optimizing health and functioning outcomes Rehabilitation can reduce Intensive Care Unit -admission related complications, such as Post Intensive Care Syndrome (PICS), Intensive care unit acquired weakness (ICUAW) The aim of rehabilitation is to improve recovery and reduce disability or the experience thereof Rehabilitation interventions address several consequences of severe COVID-19 such as: Physical impairments Cognitive impairments Swallow impairments Provision of psychosocial support It is evident that older people and people with pre-existing comorbidities are at higher risk for more severe illness. Rehabilitation can be beneficial in these populations to maintain their prior levels of functionality and independence. Early Discharge Facilitation During the pandemic, there is a high demand for hospital beds in countries worldwide, especially during the times when the pandemic reaches its peak in a country or area. This leads to patients being discharged sooner than would normally be the case. Rehabilitation is crucial in this scenario to prepare a patient for discharge, coordinating complex discharges and also to safeguard the continuity of care. Reducing the risk of readmission Rehabilitation is a key strategy to ensure that patients do not deteriorate after discharge and require readmission. During the COVID-19 pandemic, this is critical in the context of shortages of hospital beds. Physiotherapists as rehabilitation professionals are frontline healthcare professionals and should be engaged in the care of patients suffering from severe cases of COVID-19 A patient who has severe COVID-19 will go through multiple phases of care – acute, post-acute and long term care. In the acute phase, care will most likely be provided in the ICU or critical care units. In the post-acute phase, care will most likely be provided in a hospital ward, or a step-down or rehabilitation facility. The long-term phase will be when patients return home and are still recovering and will receive rehabilitation at community level. Physiotherapy and the Post-Acute COVID-19 Rehabilitation Phase Physiotherapists are instrumental in the rehabilitation of patients as they transition from the acute phase to the post-acute phase.[4] The consequences of COVID-19 will be specific in each individual and their rehabilitation needs will be specific to these consequences such as: Long term ventilation Immobilisation Deconditioning Related impairments – respiratory, neurological, musculoskeletal COVID-19 patients will often present with pre-existing comorbidities and this must be taken into consideration in the rehabilitation plan for the patient. Physiotherapists working across various disciplines should work together and draw on the expertise of each other.[4] The transition from the acute to the post-acute phase needs to be supported through service delivery pathways and the multidisciplinary team will be key to this. COVID-19 Patient Presentation in the Rehabilitation Unit Factors to consider in creating a rehabilitation plan for survivors of COVID-19 include[5]: Comorbidities Direct lung trauma Injuries to other organs and systems due to COVID-19 Comorbidities There is clear evidence from across the world that the leading co-morbid conditions of people with COVID-19 include[6]: Hypertension Coronary artery disease Stroke Diabetes Considering that these conditions are often associated with ageing, it is most likely that survivors of COVID-19 are older people with pre-existing conditions such as cardiovascular and cerebrovascular disease. This will have an influence on rehabilitation needs as well as rehabilitation outcomes.[5] Severe COVID-19 Complications Early complications of COVID-19 include[6]: Acute respiratory distress syndrome (ARDS) Sepsis or septic shock Multi-organ failure Acute kidney injury Cardiac injury These complications often lead to the person being admitted to an Intensive Care Unit (ICU). Conditions that may arise from lengthy ICU-stays include[7]: Critical Illness Polyneuropathy (CIP) Critical Illness Polyneuropathy is a mixed sensorimotor neuropathy that may lead to axonal degeneration and studies have shown that patients hospitalised in ICU with ARDS may present with CIP. Critical illness polyneuropathy (CIP) causes several difficulties such as[8]: Difficulty weaning from mechanical ventilation Generalized and symmetrical weakness (distal greater than proximal, but does also include diaphragmatic weakness) Distal sensory loss Atrophy Decreased or absent deep tendon reflexes Critical Illness Polyneuropathy is associated with[8]: Pain Loss of range of motion Fatigue Incontinence Dysphagia Anxiety Depression Post-traumatic Stress Disorder (PTSD) Cognitive loss Critical Illness Polyneuropathy is diagnosed through: Muscle biopsies Electromyographic testing Critical Illness Myopathy (CIM) This condition is present in 48 – 96% of patients in ICU with ARDS.[8] It is a non-necrotising diffuse myopathy with fatty degeneration, fibre atrophy and fibrosis. CIM is associated with: exposure to corticosteroids, paralytics and sepsis. It has a similar clinical presentation to CIP but with more proximal weakness and sensory preservation[9]. Patients recover more completely from myopathies than polyneuropathies, but with both conditions, there are long term consequences to consider such as: Weakness Loss of function Loss of quality of life Poor endurance Post Intensive Care Syndrome (PICS) A distinct feature of COVID-19 is that, when necessary, acute and ICU care, as well as ventilator reliance, is often required for considerably longer periods. The aftershock as a result of this long ICU period will be felt for many months and years.[9] Characteristics of PICS include[9]: Cognitive impairments Memory Attention Visuo-spatial Psychomotor Impulsivity Psychiatric Illness Anxiety Depression PTSD Physical Impairments Dyspnea/ Impaired pulmonary function Reduced inspiratory muscle strength Pain Sexual dysfunction Impaired exercise tolerance Neuropathies Muscle weakness/Paresis Poor upper extremity and grip strength Poor knee extension Severe fatigue Low functional capacity The neuromuscular complications from PICS often result in poor mobility, falls and even quadriparesis. Risk factors for Post Intensive Care syndrome[9]: Delirium Duration of ICU admission Duration of sedation Duration of mechanical ventilation Age Hypoxia and hypotension Sepsis Glucose dysregulation Premorbid mental and physical comorbidity Throughout the world, healthcare systems will be inundated with a cohort of post-ICU patients created by the COVID-19 pandemic. It is therefore important to have a coordinated rehabilitation response.[9] Persistence of SARS-CoV-2 Virus Patients who have physically recovered and who have two negative tests after infection are considered to be cured and non-infectious.[10] There are however reports of patients testing positive again at a later stage. Studies have also shown that the virus may persist in a persons’ oropharyngeal cavity and stools for up to 15 days after they have been declared cured.[10][11] This needs to be considered when patients are being discharged to the ward or rehabilitation facilities as they still might be able to transmit the disease. Sequelae after COVID-19 Infection Cardiac sequelae Studies have shown that hospitalised patients with COVID-19 also had associated cardiac injury. The mechanism of cardiac injury is uncertain, however. Patients with this associated cardiac injury presented with[12]: Arrhythmia Cardiac insufficiency Ejection fraction decline Troponin I elevation Severe myocarditis with reduced systolic dysfunction The presence of cardiac injury, as well as other comorbidities, need to be considered for patients entering post-acute rehabilitation.[5] Neurological sequelae Numerous neurological symptoms have been reported in patients with COVID-19[13]. The scoping review of the available literature on COVID-19 shows an increase in the risk of secondary neurological complications in patients hospitalised with COVID-19[14]. The symptoms include[13]: Headaches Disturbed consciousness Seizures Absence of sense and smell Parasthesia Posterior reversible Encephalopathy syndrome Viral encephalitis Increased risk for acute cerebrovascular event Reports of Guillain-Barre Syndrome associated with COVID-19 Again, these neurological factors need to be considered when a patient is entering post-acute rehabilitation after COVID-19. Musculoskeletal sequelae Perspectives from physiotherapists in Northern Italy indicate specific problems encountered in the post-acute phase[1][15]. These include: Physical deconditioning Severe muscle weakness Reduced joint mobility Neck and shoulder pain (due to prone lying) Difficulty in verticalization Impaired balance and gait CIP CIM Pulmonary sequelae Impaired lung function Lung fibrosis as sequelae of pneumonia – patients showing respiratory insufficiency needing respiratory rehabilitation Tough secretions requiring specific physiotherapy techniques or technical removal[16] Cognitive sequelae Difficult awakening with long-lasting confusional state and psychological problems Delirium and other cognitive impairments[16] Other sequelae Limitations of ADL Dysphagia Impaired swallow and communication Patients with severe COVID-19 infection seem to have lengthy and longer than usual stays in ICU and many complications due to the long period of immobilisation and prone positioning. It is important to have a gradual progression from the weaning phase to transfer to a rehabilitation service – patients need to be monitored closely and accurately as they remain unstable for several days after extubation. Procedures for Post-Acute Covid-19 Rehabilitation Patients who have recovered from the acute respiratory effects of COVID-19 will still need further rehabilitation. Guidance for rehabilitation physiotherapists Determine risk Consider the risk involved of a patient not receiving immediate rehabilitation on outcomes such as risk of hospitalization, extended hospital stay If the therapist continues with a rehabilitation assessment or treatment – point of care risk assessments should be done prior to each patient interaction[17] Try and do as much as possible without patient contact Find other innovative ways to gather information without direct contact with patients in isolation. Consider telehealth methods to conduct a subjective assessment or a pre-treatment screening or discharge planning; to observe patient mobility, etc)[17] Determine the type of Personal Protective Equipment (PPE) needed for patient contact[17] Aerosol Generating Procedures (AGP’s) The type of oxygen therapy the patient is receiving and the type of procedure conducted will determine if a procedure is aerosol-generating Therapies that require airborne precautions: High flow nasal oxygen Non-invasive ventilation Nebuliser treatment Tracheostomy tubes with/without mechanical ventilation requiring open suctioning Sputum inducing procedures require airborne precautions Respiratory physiotherapy Activities resulting in expectoration of sputum – moving from lying to sitting, walking, bedside ADL’s, prone positioning[17] Other considerations before starting direct contact treatment[17] It is critical to have a step-by-step process for donning and doffing PPE to avoid contamination Use the minimum amount of people required to safely administer a treatment session Careful consideration is needed with regards to equipment use. Be sure that it is line with infection control measures and that any equipment can be properly decontaminated. Avoid moving equipment between COVID-19 and non-COVID-19 areas. Opt for using single patient use, disposable equipment  (i.e, Theraband instead of hand weights) Suggestions for the design and procedures for an inpatient rehabilitation unit These suggestions will need to be assessed based on the unique setting of each rehabilitation unit and the specific needs of the individual patient. Many of these suggestions are extrapolated from the experiences in China and Italy as well as from the SARS epidemic.[5][13][18] A separate area or unit is necessary for the rehabilitation of post-COVID-19 patients Patients might be transferred from acute care earlier than is generally done, in order to clear beds for more patients in need of acute care Patients should stay in their rooms Therapy should be provided one on one group therapy and therapy in rehabilitation gyms should not be allowed Earlier discharge of patients (as soon as the family can take care of the patient) to free up space for incoming patients There might be difficulty in discharging patients to long-term care facilities and retirement homes as these facilities might not be taking in new residents during the pandemic Shared equipment should be decontaminated between patients Best to utilize single-use equipment where possible (Therabands instead of free weights) Special care and attention should be paid to the use of electrode sponges, heat packs, gels, topical lotions, etc Therapeutic activities should be planned to minimize the number of personnel needed (i.e. therapist with a gait/walking aid instead of a therapist and an assistant) Minimize the number of personnel in contact with a patient. Have a single staff member perform most of the care and duties for a patient Walking practice should be done in areas that are not commonly used Surgical masks should be worn by patients and therapists should be using the necessary PPE Patients should always practice social distancing among each other Personnel considerations in a rehabilitation unit Frequent health checks for rehabilitation personnel Staff shortages may arise either due to illness, isolation or redeployment Changes in staff/patient ratio – more one on one sessions Guidelines and protocols will be changing as new evidence becomes available. Continuous staff training will be paramount Personnel should be trained and re-trained in the use of PPE Physiotherapists should use higher levels of PPE if they are at risk of exposure to aerosols from post-COVID-19 patients. Ongoing input from frontline staff is important to inform other healthcare professionals Other ways of providing non-required therapies and services should be considered such as telerehabilitation Work efficiency might be affected by the use of PPE and the time it takes to don PPE, as well as infection control measures Virtual staff meetings should be held if possible[5][19] Post-acute Rehabilitation Guidelines after COVID-19 The WHO and the PAHO have compiled a document on the rehabilitation considerations during the COVID-19 outbreak[3], and the WCPT has also compiled briefing papers in response to COVID-19[4]. The second briefing paper specifically addresses rehabilitation and the vital role of physiotherapy.[4] Each patient in the post-acute rehabilitation unit should be assessed by all the relevant healthcare professionals. A suitable and manageable treatment plan should be created with input from the healthcare team and the patient. The direct impact of COVID-19 on the respiratory system and other systems, the sequelae of COVID-19 (such as a long period of ICU stay, mechanical ventilation) as well as the comorbidities involved will direct and inform the rehabilitation plan. Other factors that will affect the rehabilitation plan is the discharge destination and estimated discharge date.[5] Currently, there is limited evidence of the impact of rehabilitation after COVID-19. The information provided is based on evidence from countries such as China, Italy and other areas. This evidence is based on the experience and expert opinions of rehabilitation healthcare professionals from these regions. General rehabilitation considerations in the post-acute phase Patients recovering from an acute COVID-19 event may present with a disability or functional damage (respiratory function, CIP, CIM, PICS), reduced participation and deterioration in their quality of life (short term as well as long term post-discharge) Variable recovery time – dependent on the degree of normocapnic respiratory failure, associated physical dysfunction (asthenia, muscle weakness), emotional dysfunction; the presence of other comorbidities Clinical parameter evaluating protocols are indicated on a daily basis – temperature, SaO2, Sp02/Fi02, cough, dyspnea, respiratory rate, thoraco-abdominal dynamics Simple and repeatable protocols to wean oxygen therapy should be used Reconditioning interventions are indicated in weaned patients and those with prolonged weaning from mechanical ventilation to improve physical status and effects of prolonged immobilisation Evaluate peripheral muscular strength with MRC scale, manual muscle testing, isokinetic muscle test; measurement of joint range of motion Exercise with gradual load increase and based on subjective symptoms can help to regain and maintain normal function Consider telehealth systems for patients that need rehabilitation but who are in isolation Balance function assessment is necessary as soon as possible (especially in patients who have been bedridden for a long period) Exercise capacity and oxygenation response during effort should be assessed Respiratory rehabilitation It is recommended to not begin with respiratory rehabilitation too early to avoid aggravating respiratory distress or dispersing the virus unnecessarily. Techniques such as diaphragmatic breathing, pursed-lip breathing, bronchial hygiene, lung expansion techniques (positive expiratory pressure), incentive spirometry, manual mobilisation of the ribcage, respiratory muscle training and aerobic exercise are not recommended in the acute phase. In the event of comorbidities such as bronchiectasis, secondary pneumonia or aspiration increasing secretions, postural drainage and standing (gradual increase in time) may help with secretion management.[20] Respiratory assessment for post-acute rehabilitation should include[1][20]: Dyspnea Thoracic activity Diaphragmatic activity and amplitude Respiratory muscle strength (maximal inspiratory and expiratory pressures) Respiratory pattern and frequency Also include an assessment of their cardiac status In the post-acute phase, the following respiratory rehabilitation may be included: Inspiratory muscle training if inspiratory muscles are weak Diaphragmatic breathing Thoracic expansion (with shoulder elevation) Mobilisation of respiratory muscles Airway clearance techniques (as needed) Positive expiratory devices may be added if needed Be careful to not overload the respiratory system and causing respiratory distress! A randomised controlled trial from China implemented a respiratory rehabilitation program consisting of 2 sessions of 10 minutes per week for 6 weeks post-discharge from acute care. The study results showed a significant improvement in respiratory function, endurance, quality of life and depression. The respiratory rehabilitation programme included respiratory muscle training with positive expiratory pressure device, cough exercises, diaphragmatic training, chest stretching and pursed-lip breathing.[21] Aspects to monitor closely in patients include[20]: Shortness of breath Decreased SaO2 (<95%) Blood pressure (< 90/60 or > 140/90) Heart rate (>100 beats per minute) Temperature (> 37.2 C) Excessive fatigue Chest pain Severe cough Blurred vision Dizziness Heart palpitations Sweating Loss of balance Headache Patients in post-acute rehabilitation can start a multidisciplinary team rehabilitation program. Concepts of pulmonary rehabilitation can be applied, but keep in mind that pre-rehabilitation assessments such as formal lung function and exercise testing is probably not feasible at the start and cannot be done in infectious patients. Exercise training may have to start with relatively simple graded functional and strengthening exercises, using no or minimal equipment.[22] Functional rehabilitation Recommendations on functional rehabilitation from the European Respiratory Society include: Assessment of exercise and functional capacity Monitoring of pre-existing conditions Exercise training and/or physical activity coaching Functional Rehabilitation aspects to assess[1]: Muscle and joint range of motion Strength testing Balance    Exercise capacity – assess with the 6-minute walking test (continuous oxygen saturation monitoring included) Cardiopulmonary exercise testing Activities of Daily Living (ADL) Clinical outcome measures It is recommended to use easily applicable tests, as advanced equipment to assess the functional capacity of patients may not be available or safe to do during the pandemic. Clinical outcome measures that can be used[1][23]: Patient Specific Functional Scale to identify perceived limitations in activities of daily living Monitor patient’s oxygen saturation and heart rate frequency before, during and after physical activity and exercises Use Borg Scale CR10 for shortness of breath and fatigue International Physical Activity Questionnaire to measure function and disability Physical Activity Scale for the Elderly to measure function and disability Berg Balance Scale 6 Minute Walking Test – to assess exercise capacity Barthel Index to measure ADL Short Physical Performance Battery 30 seconds sit to stand test Handgrip dynamometer test Manual muscle strength test The multidisciplinary team should aim to use the same clinical outcomes for the same constructs to facilitate communication between team members and not burden the patient unnecessary. Specific Physiotherapy Interventions Ways of early mobilisation include[24]: Frequent posture changes Bed mobility Sit to stand Simple bed exercises ADL’s It is important to monitor the patient’s respiratory and hemodynamic state during rehabilitation! Active limb exercises should be followed by progressive muscle strengthening (suggested programs 8-12 RM load for 8 -12 repetitions, 1 to 3 sets with 2 minutes rest between sets, 3 sessions a week for 6 weeks)[1] Neuromuscular electrical stimulation can be used to help with strengthening. Aerobic reconditioning can be achieved with walking, cycle or arm ergometry, NuStep cross trainer Keep aerobic activity less than 3 metabolic equivalents of task (MET’s) initially Progressive aerobic exercise can later be increased to 20 -30 minutes Education on energy conservation and behavior modification[5] Advice on exercise as medicine Gradual increase of daily living activities and physical functioning Provide patient with exercises that support recovery in daily function All activities should be well monitored especially in patients with PICS Perform exercises at low to moderate intensity and off limited duration. Keep in mind that patients who have been admitted to ICU and who show symptoms of PICS will have a very low capacity to perform activities and exercise. The activity levels of the patient prior to COVID-19 infection, the patient’s needs and the current physical abilities of the patient will determine the specific parameters for exercise prescription Recommendation of a maximum score of 4/10 on Borg Scale CR10 for shortness of breath and fatigue during the post-acute rehabilitation phase as patients have reduced lung function after COVID-19 infection and cardiac function may possibly be affected after COVID-19 infection. No maximal exercise testing is done after active COVID-19 infection – limitations due to pandemic. So there will not always be adequate clinical information to determine a patient’s specific parameters for exercise prescription and also not possible to estimate the risk involved of physical training at a moderate/high intensity. Prescribe exercises with training parameters regarding frequency, intensity, time/duration and type[23] Multidisciplinary team involvement Various members of the multidisciplinary team will be involved in the post-acute rehabilitation phase of survivors of severe COVID-19. Some of these team members include[17]: Occupational therapists Focus ADL and instrumental ADL guidance Interventions to facilitate functional independence Help to prepare the patient for discharge Can address cognitive changes Speech and language pathologists/therapists Assess and treat dysphagia as a result of intubation Assess and treat voice impairments as a result of prolonged intubation Address communication issues Education on healthy lifestyle and the importance of participating in family and social activities should be provided to the patient. Psychological interventions should be provided where required for patients by occupational therapists, social workers or rehabilitation psychologists. Chinese medicine techniques (tai chi, Qigong, guided breathing) have been suggested by the Chinese Actions for Rehabilitation Service Providers These are actions that rehabilitation facilities, private practices and hospitals can take during the COVID-19 pandemic to improve and ensure quality service delivery.[3] Stay informed on the outbreak status and regional and national guidelines regarding COVID-19 Set-up communication links with all relevant COVID-19 coordination bodies and networks Source, disseminate and enforce COVID-19 guidelines and protocols Ensure frequent communication with patients and distribute important information Rehabilitation should be integrated into Infection Prevention and Control (IPC) measures and healthcare workers should use Personal Protective Equipment (PPE) appropriate to their risk exposure Have set protocols for IPC (to whom, when, and how these apply) Rehabilitation professionals like physiotherapists may engage in the delivery of Aerosol Generating Procedures (AGP’s) and the essential PPE is required for this The rehabilitation workforce (and family members) should have priority access to COVID-19 testing IPC training is critical to all rehabilitation professionals Increase the rehabilitation workforce for the post-acute and long-term recovery phases after COVID-19 Address workforce shortages Source rehabilitation professionals from areas such as retired workforce, trainees, academics, private practice Develop competency-based training and supervision for professionals who are rejoining the rehabilitation workforce or shifting their roles to provide support Ensure productivity of the existing workforce by implementing measures such as leave postponement, modifying shift structures, increasing part-time contract to full time Identify high-risk rehabilitation healthcare professionals and define clear and strict conditions for their practice The wellbeing of rehabilitation professionals can be supported by monitoring for and taking steps to prevent burnout, and guarantee access to psychosocial support Additional equipment Attain additional equipment needed for the surge in rehabilitation demand related to COVID-19 patients, such as pulse oximeters, rehabilitation equipment such as hoists, walking aids, equipment used during respiratory/pulmonary rehabilitation such as stationary bikes Attain additional assistive devices that can support early discharge, such as walking frames, commode chairs, mattresses and transfer products Rehabilitation clinical management for COVID-19 patients Implement clinical management guidelines and protocols of care related to COVID-19 patients based on best available evidence Adaptable rehabilitation resources for COVID-19 patients who experience ongoing respiratory and physical deconditioning should be available These may include: Exercise programs with graded exercises Pacing strategies Behavior modification Advice on positioning Recognition of red flags such as signs of medical deterioration Implement systems for tracking COVID-19 patients and remote-follow-up Implement referral pathways and develop contact lists for services required by COVID-19 patients Rehabilitation practices modification for Infection control Develop and implement protocols for the management of rehabilitation equipment and assistive devices to reduce infection risk Prepare rehabilitation professionals for the impact of PPE such as the time involved donning and doffing PPE and the impact it will have on patient rapport Plan for working in different teams to reduce therapist-patient exposure Amendments to the scope of practice and more interdisciplinary practice to minimize patient’s contact with multiple professionals Multidisciplinary teamwork will be more virtual meetings than face to face interactions Address barriers to telehealth such as technology, devices, network  and costs Group patients beds and adjust the spacing to reduce the risk of infection Rehabilitation sessions should rather be done within a patient’s bed space in order to restrict the movement of patients within a rehabilitation facility Avoid the use of shared therapy spaces such as gyms Develop protocols for patient discharge to maximize bed availability and minimize the patient time in the rehabilitation facility Encourage and ensure access to psychosocial support for patients Increased levels of anxiety and depression as seen in COVID-19 patients. Ensure that patients have access to the support that they need during their rehabilitation process Be aware of patients’ normal family or support structure being disrupted due to the COVID-19 outbreak. Facilitate support such as communication with family members. Provide training and access to psychological first aid skills for rehabilitation professionals Implement peer support mechanisms Resources Italian suggestions for pulmonary rehabilitation in COVID-19 patients recovering from acute respiratory failure: results of a Delphi process Rehabilitation considerations during the COVID-19 outbreak WCPT response to COVID-19 Briefing paper 2. Rehabilitation and the vital role of Physiotherapy. Physiotherapy recommendations in patients with COVID-19 Post-COVID rehabilitation and management strategies The Stanford Hall consensus statement for post COVID-19 rehabilitation



  1. Jump up APTA Statement on Patient Care and Practice Management During COVID-19 Outbreak. 17 March 2020 Accessed 18 March 2020.
  2. Jump up World Health Organization. Medical and fabric masks: who wears what when? Available from [last accessed 7/8/2020]
  3. Jump up WHO. Q&A on coronaviruses (COVID-19). 9 March 2020
  4. Jump up CDC. Coronavirus Disease 2019 (COVID-19). How to Protect Yourself
  5. Jump up World Health Organisation. Advice on the use of masks in the community, during home care and in health care settings in the context of the novel coronavirus (2019-nCoV) outbreak. Accessed 14 March 2020
  6. ↑ Jump up to:6.0 6.1 6.2 World Health Organisation. Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts. Accessed 14 March 2020
  7. Jump up World Health Organisation. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19). Accessed 14 March 2020
  8. Jump up Centers for Disease Control and Prevention (CDC). 10 Things You Can Do to Manage COVID-19 at Home. Published on 13 March 2020. Available from [last accessed 18 March 2020]
  9. Jump up World Health Organisation. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. 13 March 2020. Accessed 18 March 2020.
  10. ↑ Jump up to:10.0 10.1 Rachael Moses. COVID 19: Respiratory Physiotherapy On-Call Information and Guidance. Lancashire Teaching Hospitals. Version 1 dated 12th March 2020
  11. ↑ Jump up to:11.0 11.1 Rachael Moses. Physiotherapy Interventions for COVID-19. 18 March 2020. Accessed 19 March 2020
  12. ↑ Jump up to:12.0 12.1 12.2 12.3 Australian and New Zealand Intensive Care Society. ANZICS COVID-19 Guidelines. Melbourne: ANZICS  2020
  13. Jump up Lazzeri M, Lanza A, Bellini R, Bellofiore A, Cecchetto S, Colombo A, D’Abrosca F, Del Monaco C, Gaudellio G, Paneroni M, Privitera E. Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Monaldi Archives for Chest Disease. 2020 Mar 26;90(1).
  14. Jump up David A. Autogenic Drainage – the German approach. In: J. Pryor, editor. Respiratory Care, Edinburgh: Churchill Livingstone; 1991
  15. Jump up Pryor JA. Physiotherapy for airway clearance in adults. European Respiratory Journal.1999;14: 1418-1424
  16. Jump up Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK. Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness. Eur Respir J. 2003;21:502-508.
  17. Jump up Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists
  18. Jump up World Health Organisation. Global Surveillance for human infection with coronavirus disease (COVID-19). Accessed 14 March 2020
  19. Jump up Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, Hodgson C, Jones AYM, Kho ME, Moses R, Ntoumenopoulos G, Parry SM, Patman S, van der Lee L (2020): Physiotherapy management for COVID-19 in the acute hospital setting. Recommendations to guide clinical practice. Version 1.0, published 23 March 2020
  20. Jump up WCPT and INpTRA. Report of the WCPT/INPTRA Digital Physical Therapy Practice Task Force. May 2019. Accessed online 14 March 2020
  21. Jump up Irish Society of Chartered Physiotherapists. POLICY and GUIDELINES on e-HEALTH for Physiotherapists in Private Practice. March 2020. Accessed online 14 March 2020
  22. Jump up Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. Journal of telemedicine and telecare. 2018 Jan;24(1):4-12.
  23. Jump up Phzio Telehealth. COVID-19 Phzio Virtual Care Treatment. Published on 13 March 2020. Available from [last accessed 18 March 2020]

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Thomas Bloem
Thomas Bloem

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