PHOTO CAPTION: Studies have emphasized the importance of early mobilization, which has been shown to lead to improved functional outcomes.
by Justine Mamone-Lucciola, PT, DPT, and Dana Zeitlin, PT, DPT
Coronavirus 2019 (COVID-19) is a novel coronavirus recognized to be highly contagious with symptoms occurring between 2 to 10 days post-transmission.1,2 According to the World Health Organization, as of October 1, 2020, there are 7,115,491 total COVID cases and 204,642 total deaths due to COVID in the United States and rising. COVID-19 presents itself with a multitude of symptoms, including fever (89%), cough (68%), fatigue (38%), sputum production (34%), and shortness of breath (19%).1 There are several pre-existing health conditions that may influence the severity of the disease and result in increased risk for severe illness from COVID-19.2 Individuals with moderate to severe cases of COVID-19 often suffer significant pulmonary complications and potentially require mechanical ventilation. In addition to pulmonary complications, individuals may also present with severe extra-pulmonary conditions.3 These medical conditions can lead to prolonged hospitalization resulting in secondary health issues including pressure injuries, ICU-acquired weaknesses, and delirium.4
Given the medical complexity of patients hospitalized due to COVID-19, many benefit from an Acute Inpatient Rehabilitation Facility (IRF) admission following their hospital stay. Kessler Institute for Rehabilitation (KIR), in Saddle Brook, New Jersey, began admitting individuals at the start of the pandemic for COVID-19-related illnesses. Many of these individuals required rehabilitation services to address medical complexities and physical impairments. In order to meet the criteria for admission, individuals must be sufficiently medically stable, require 24-hour physician and nursing oversight, be able to actively participate and benefit from a comprehensive rehabilitation program, and require at least two therapy services—one of which must be physical or occupational therapy. As per CMS guidelines, individuals while at an IRF are required to meet the “3-hour rule” and receive 3 hours of therapy services per day. However, due to the unprecedented nature of COVID-19, this rule was waived by Medicare to accommodate the needs and tolerance to therapeutic intervention.5 This allowed for frequency and timing of therapy services to be individualized based on the severity of symptoms.
The degree and severity ranged greatly, and several impairments were present for everyone. Deconditioning was one of the most significant impairments identified upon arriving at KIR. The cause and severity of deconditioning is multifactorial as these individuals required prolonged hospitalizations and experienced profound respiratory compromise. COVID-19 also effects the cardiovascular system and the central nervous system. Cerebrovascular accidents (CVAs) due to abnormalities in coagulation added to the complexities and challenges of rehabilitation.4,6
Individualized Approach to Care
Research studies have emphasized the importance of early mobilization, which has been shown to lead to improved functional outcomes and greater potential for discharge to home.7 Many of the conventional therapy interventions utilized to treat individuals with COVID-19 were congruent with principles of stroke rehabilitation. Each plan of care developed required careful consideration for the management of additional variables including wound care, oxygen needs, peripheral nerve injuries, orthostatic hypotension, and profound weakness. In the early stages of recovery, emphasis was placed on positioning within the hospital bed for ventilatory support and airway clearance. Positioning an individual on their stomach for a period of time, proning, was performed to improve oxygenation and decreased mortality.8,9 Proning protocols were widely utilized throughout acute care facilities and were continued during IRF admission. Individuals were also placed in side-lying positions, hook lying, and supported sitting with the head of the bed elevated. Education about performing breathing exercises while in these positions was provided. During this stage of recovery, therapists reviewed a supine exercise program with emphasis on range of motion, upper extremity, lower extremity, and core strengthening to minimize further deconditioning. After initial review with the therapist, individuals performed these programs independently and in addition to their scheduled therapy time.
Back on Their Feet
As individuals improved and vital signs stabilized, therapists initiated activities that emphasized upright tolerance. Individuals were progressed in this order: semi-supine to short sit followed by unsupported sitting at the edge of the bed and transferring from the bed to the wheelchair. Once able to transfer to a wheelchair, there was an emphasis on increasing sitting duration. Commonly, a goal at this stage was to complete self care tasks seated within the wheelchair without the need to return to supine for a rest break. An additional exercise program was provided at this time to be performed when seated in the wheelchair independently.
Standing tolerance was initiated, frequently with use of an assisted standing device. These devices assisted with improving upright standing tolerance, pressure relief, lung expansion and airway clearance. The devices utilized at KIR for standing were able to be transitioned to assisted ambulation devices. These therapeutic walkers provided increased trunk support and offered body weight support facilitating early ambulation. As individuals progressed in their recovery and their ambulation became functional, appropriate walking devices were selected to maximize functional independence and reduce risk of falls. Frequently, therapists would prescribe ankle-foot orthoses as needed due to the common presence of foot drop. It was also important to closely monitor oxygen saturation with activity and ambulation to assess need for supplemental oxygen at time of discharge.
Education is Essential
A primary focus of IRF is on education to ensure a viable and safe discharge plan. Patient/caregiver education and hands-on training are standards of practice and conventionally performed in person. However, due to COVID-19, visitor restrictions were implemented and in-person training was not performed, posing a challenge for discharge planning. Phone calls and virtual education were performed in lieu of in-person training. Exceptions were made to allow one family member to participate in an in-person training with required personal protective equipment when it was essential for a safe discharge. In-person training was necessary for individuals who required physical assistance as well as nursing and medical needs at time of discharge. Despite the complexity of these individuals’ illness and adjustments to IRF protocols, many were successfully discharged to home.
Foundation for Success
IRF’s have played a major role in safely discharging many patients with COVID-19. Modifications were made to adhere to safety regulations and restrictions due to the pandemic. Despite the changes in conventional protocols, our rehabilitation programs utilized the established therapy methods to provide quality care for this population. A multidisciplinary approach was essential to achieving maximal outcomes including progressing functional mobility, identifying durable medical equipment needs, and providing appropriate education for safe home discharge.10 RM
Justine Mamone-Lucciola, PT, DPT, is a Board-Certified Clinical Specialist in Neurologic Physical Therapy Inpatient Clinical Specialist Physical Therapist at Kessler Institute for Rehabilitation, Saddle Brook Campus.
Dana Zeitlin PT, DPT, is an Inpatient Physical Therapist, Clinical Specialist, at Kessler Institute for Rehabilitation, Saddle Brook, NJ. For more information, contact RehabEditor@medqor.com.
- Thomas P, Baldwin C, Bissett B, et al. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother. 2020;66(2):73-82. doi: 10.1016/j.jphys.2020.03.011
- Gulati A, Pomeranz C, Qamar Z, et al. A comprehensive review of manifestations of novel coronaviruses in the context of deadly COVID-19 global pandemic. Am J Med Sci. 2020;360(1):5-34. doi: 10.1016/j.amjms.2020.05.006
- Centers for Disease Control and Prevention. People with certain medical conditions. Updated June 25, 2020. Accessed July 1, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Fgroups-at-higher-risk.html.
- Lopez M, Bell K, Annaswamy T, Juengst S, Ifejika N. COVID-19 guide for the rehabilitation clinician: A review of non-pulmonary manifestations and complications [published online ahead of print, 2020 May 26]. Am J Phys Med Rehabil. 2020;10.1097/PHM.0000000000001479. doi: 10.1097/PHM.0000000000001479
- Inpatient Rehabilitation Facilitates: CMS flexibility to fight COVID-19. Centers for Medicare & Medicaid Services website. Updated on July 9, 2020. Accessed October 1, 2020. https://www.cms.gov/files/document/covid-inpatient-rehab-facilities.pdf
- Janardhan V, Janardhan V, Kalousek V. COVID-19 as a Blood Clotting Disorder Masquerading as a Respiratory Illness: A Cerebrovascular Perspective and Therapeutic Implications for Stroke Thrombectomy. J Neuroimaging. 2020 Sep;30(5):555-561. doi: 10.1111/jon.12770
- Kanejima Y, Shimogai T, Kitamura M, Ishihara K, Izawa K. Effect of early mobilization on physical function in patients after cardiac surgery: a systematic review and meta-analysis. Physiotherapy. 2017; 103(1): 1-12. doi: 10.1016/j.physio.2016.08.003
- Elharrar X, Trigui Y, Dols A, Touchon F, et al. Use of prone positioning in nonintubated patients with patients with COVID-19 and hypoxemic acute respiratory failure. JAMA. 2020; 323(22):2336-2338. doi: 10.1001/jama.2020.8255
- Paul V, Patel S, Royse M, Odish M, Malhotra A, Koenig S. Proning in non-intubated (PINI) in times of COVID-19: Case series and a review. J Intensive Care Med. 2020; 35(8):818-824. doi: 10.1177/0885066620934801
- Lew HL, Oh-Park M, Cifu DX. The war on COVID-19 pandemic: role of rehabilitation professionals and hospitals. Am J Phys Med Rehabil. 2020 Jul;99(7):571-572. doi: 10.1097/PHM.0000000000001460
Fall Protection Technology for Stroke Rehab
by Frank Long, Editorial Director, Rehab Management
Researchers have observed that the physical inactivity of COVID-19 patients caused by isolation or limited access to hospitals and therapy elevates secondary stroke risk.1 These associations suggests increasing numbers of COVID-19 patients will have stroke-related walking impairment. As a result, rehab facilities must ask themselves how to best provide therapy to this population and how to protect patients from falling while they practice therapeutic interventions.
Dynamic Fall Protection
In some cases, allowing a patient to begin falling so he or she can self-correct may be beneficial in regaining the ability to walk. This type of practice can be facilitated by a body weight support device that allows freedom of multidirectional movement while also protecting patients as they practice gait, balance, transfer, and stair exercises. This type of function, known as dynamic fall protection, is designed to distinguish between a patient’s intentional movement downward and a fall. The function enables therapists to safely challenge patients and facilitate error. The technology allows therapists a wide latitude to safely challenge patients during functional mobility tasks.
One manufacturer offers a dynamic fall protection system specifically to the rehabilitation market that is attached to ceiling structures so that support is provided from overhead. A rail is attached to the structures on which a remote-controlled tram glides along, with a harness attached to support and protect the patient practicing dynamic movements. The system allows for hands-free operation, and no staff members are needed to support the patient.
Another type of body weight support technology that is useful for stroke rehabilitation are mobile robotic devices designed as frames on wheels that allow patients to walk over ground, over a treadmill, or over any surface the wheels will accommodate. This system is relatively compact yet still provides hands-free, overhead support and fall protection. The design of this technology also allows a built-in patient lift to facilitate transfers into and out of a wheelchair. Once the patient is safely strapped inside the harness, he or she can engage in self-directed walking without risk of injury to themselves or staff members. RM
- Dailey ER. COVID-19 and its connection to stroke. Accessed Nov. 23, 2020. Available at https://www.pinnaclehealth.org/wellness-library/blog-and-healthwise/blog-home/post/covid-19-and-its-connection-to-stroke
- Wang C, Chao J, Wang ML, et al. Care for patients with stroke during the COVID-19 pandemic: physical therapy and rehabilitation suggestions for preventing secondary stroke. J Stroke Cerebraovasc Dis. 2020;29(11):105-182.