Like the virus itself, the road to recovery from COVID-19 isn’t straightforward.
While the infection mainly affects the lungs, it can have a cascading effect on a person’s physical health.
It’s something physiotherapists like Michelle Kho have seen first-hand.
“There’s a team fighting to keep a person alive. Physiotherapy is part of that team,” said Kho, who works in the intensive care unit (ICU) at St. Joseph’s Healthcare in Hamilton, Ont.
“I believe we’re at the tip of the iceberg for understanding how we need to support these survivors.”
Kho has worked with severely ill COVID-19 patients over the last few months. Much of the care follows “basic principles of physiotherapy,” she said, but the new virus has created new challenges.
“They’re so sick that they’re not moving,” she said. “They’re not using their muscles and they’re developing tremendous weakness… Patients who are on prolonged bed rest are certainly at high risk.”
Movement is key
There’s a wide variation of how long a patient who requires ICU care — and survives — stay there. In China, it’s an average of eight days, in Italy, it’s nine days, and in the United States, it’s upwards of 14 days.
Depending on the length, a person’s health can be impacted in a variety of ways.
Clinical studies in Italy of patients who had long ICU stays show the onset of “severe muscle weakness, fatigue, joint stiffness, dysphagia (swallowing difficulties), neuropsychological problems and impaired mobility and functioning,” World Physiotherapy reported.
It can also put them at greater risk of developing post-intensive care syndrome (PICS) — physical, cognitive and psychological changes that occur after surviving an illness or injury that requires treatment in the ICU.
For these reasons, the sooner a physiotherapist can get involved in the rehabilitation of a COVID-19 patient, the better, said Kho. That often happens once a patient is considered “medically stable” and can “start to follow some commands.”
It could be as simple as readjusting in a hospital bed, Kho said.
“There’s nothing more rewarding than helping someone to sit at the edge of the bed for the first time again in weeks or stand again for the first time or take a first few steps,” she said.
But the virus, and protocols surrounding it, have brought challenges, she said.
Hospitalized COVID-19 patients must stay in a small room at all times, making it tricky for physiotherapists to rehabilitate patients and prepare them for the demands of the day once they’re cleared to return home, Kho said.
It also makes communicating with a patient an obstacle, she said.
Since the virus attacks the respiratory system, patients often cough repeatedly and have trouble breathing. Patients in the ICU are often intubated or on a ventilator.
“It makes it difficult for them to talk. So it makes it even more challenging for us because it’s tough for them to tell us what they need,” she said.
“But we have a sense of what to expect. We know a lot about this from our ICU patients over the last 20 to 25 years.”
The consequences of long-term ICU stays are well studied.
Kho pointed to research done by Dr. Margaret Herridge, a respirologist and critical-care physician in Toronto, who has co-authored dozens of papers on the outcomes after critical illness in patients in the ICU. Herridge is also leading a nationwide study to understand the recovery trajectories of patients with COVID-19, of which Kho’s hospital in Hamilton is a part.
One of her studies found that critically ill people requiring ICU care at six Toronto-area hospitals who were previously healthy and young never regained the physical health they had before their illness, even five years after being discharged.
Each of the patients studied had acute respiratory distress syndrome (ARDS), a severe form of lung injury and inflammation, which COVID-19 can bring on.
Other studies emphasize the need for early physical therapy to improve outcomes for critically ill adults to avoid “functional decline and disability” once they leave the hospital.
Kho said much of this evidence is applicable now, even if the illnesses aren’t the same.
“We know that someone could have impairments during a six-minute walk endurance test up to five years later,” she said.
“These are patients who we already sort of understand what their rehabilitation trajectory is going to be like. If we take that patient population and apply what we know about these COVID-19 patients, we know that there’s going to be a long road ahead of them.”
The importance of movement in that road to recovery can’t be understated, according to Amy Ellis, a physiotherapist working with COVID-19 patients in British Columbia.
There’s a “big spectrum of patients,” she said, so not all will need the same type of rehabilitation, but COVID-19 has fostered innovation in the field.
One such innovation is getting patients out of bed while they’re still on a ventilator.
“I think that surprises people,” she said. “But there’s a huge push globally in increasing early mobility. It can help them get off the ventilators sooner, get them stronger. They have actually tolerated getting up, even while ventilated.”
There’s also been a wider push to “prone” seriously ill patients, she said. The technique, called prone positioning, involves putting a person on their belly to help increase airflow to their lungs. It was first demonstrated by an urgent care specialist in Britain but has since spread to hospitals worldwide.
“It’s been an area of growth for everyone, but physio really has a role to play in it because it’s about positioning, it’s about how the human body tolerates that position and what we can do to keep them comfortable in that position for a long period of time,” Ellis said.
“We’re not just looking at how do we make you better but what we can do early on to help you be less impacted functionally.”
Ellis and Kho agreed that it’s still too early to quantify the amount of rehab or long-term care required months and years after recovering from the virus. For some, it may be extensive, but for others, it may be next to none.
“How you come into the disease is going to impact where you come out functionally,” Ellis said. “We’ve had younger people significantly impacted, and I’ve had a 90-year-old patient who picked up really quickly and was very excited to go home.”
She put it simply: “If you don’t use it, you lose it.
“To us, it’s not like you just go and run a marathon, you have to build yourself up into it. That’s the principle we apply to someone that’s recovering from COVID-19.”