Comprehensive physiotherapy management in covid-19 – a narrative review

Recebido em: 13 mar.2020. Aprovado em: 21 mai. 2020. Publicado em: xx xxx. 2020. ABSTRACT: The 2019 novel coronavirus officially named as coronavirus disease 2019 (COVID-19) pandemic by the World Health Organization, has spread to more than 180 countries. The ongoing global pandemic of severe acute respiratory syndrome coronavirus, which causes COVID-19, spread to the United Kingdom (UK) in January 2020. Transmission within the UK was confirmed in February, leading to an epidemic with a rapid increase in cases in March. As on April 252020, there have been 148,377 confirmed cases of COVID-19 in the UK and 20,319 people with confirmed infection have died. Survival of critically ill patients is frequently associated with significant functional impairment and reduced health-related quality of life. Early physiotherapy and community rehabilitation of COVID-19 patients has recently been identified as an essential therapeutic tool and has become a crucial evidence-based component in the management of these patients. This comprehensive narrative review aims to describe recent progress in the application of physiotherapy management in COVID 19 patients. Assessment and evidence-based treatment of these patients should include prevention, reduction of adverse consequences in immobilization, and long-term impairment sequelae. A variety of techniques and modalities of early physiotherapy in intensive care unit are suggested by clinical research. They should be applied according to the stage of the disease, comorbidities, and patient’s level of cooperation.

da doença por coronavírus 2019 (COVID-19) pela Organização Mundial de Saúde, se espalhou para mais de 180 países. A pandemia global em curso da síndrome respiratória aguda grave causada pela COVID-19, se espalhou para o Reino Unido em janeiro de 2020. A transmissão no Reino Unido foi confirmada em fevereiro, levando a um rápido aumento de casos em março. Em 25 de abril de 2020, houve 148.377 casos confirmados de COVID-19 no Reino Unido e 20.319 pessoas, com infecção confirmada, morreram. A sobrevivência de pacientes críticos está frequentemente associada ao comprometimento funcional significativo e redução da qualidade de vida relacionada à saúde. A fisioterapia precoce e a reabilitação comunitária de pacientes com COVID-19 foram recentemente identificadas como uma ferramenta terapêutica essencial e tornaram-se um componente crucial baseado em evidências no tratamento desses pacientes. Esta revisão abrangente tem como objetivo descrever o progresso recente na aplicação do manejo da fisioterapia em pacientes com COVID-19. A avaliação e o tratamento baseado em evidências desses pacientes devem incluir a prevenção, a redução de consequências adversas da imobilização e as sequelas de comprometimento a longo prazo. Uma variedade de técnicas e modalidades de fisioterapia precoce em unidade de terapia intensiva são sugeridas por pesquisas clínicas. Eles devem ser aplicados de acordo com o estágio da doença, com as comorbidades e com o nível de cooperação do paciente.  [4]. The first few cases were identified in late January [4], and transmission within the UK was confirmed in late February [5], followed by a rapid increase in March [6]. As of April 25 [7]. However, the remaining will be severely affected and will require intensive medical care. Although difficult to accurately estimate, the World Health Organization reports a case fatality rate of 3.4% [7]. Moreover, in the case of SARS which is another contagion in Patients who stay longer are more likely to develop muscle wasting, neuropathies, loss of mobility, loss of function and weakness. The under-recognized post intensive care syndrome is associated with poor long-term outcomes, especially for patients who have had acute respiratory distress syndrome, prolonged ventilation and sepsis. [10,11] Currently, we do not know the longer-term physical, physiological and psychological outcomes for this novel corona virus. However, there is some evidence from the SARS, Middle East respiratory syndrome, influenza A (H7N9) and H1N1 epidemics describing longer-term ongoing reduction in pulmonary function, reduced quality of life as well as physical function [12,13] This article has been prepared to provide information to physiotherapists in the management of hospital admitted patients with confirmed or suspected COVID-19. Physiotherapists who work in primary healthcare facilities are likely to have a role in supporting these patients who would benefit from the respiratory physiotherapy assessment

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and management of productive cough which is a less but not unusual symptom (34%) [14]. However, physiotherapists who work in the intensive care unit (ICU) provide airway clearance techniques for ventilated patients who show signs and symptoms of inadequate airway clearance. They can also help in positioning patients with severe respiratory failure associated with COVID-19, inclusive of using susceptible position to optimize oxygenation [15].
Given the in-depth medical management for some COVID-19 patients including prolonged protective lung ventilation, sedation and use of neuromuscular blockading agents, patients with COVID-19 who are admitted to ICU may be at high risk of developing ICU acquired weakness [16]. This might lead to worsening of their morbidity and mortality [17] and therefore essential to anticipate dysfunction [41]. Patients with comorbidities will take a more extended period to return to their earlier condition, protocols for evaluating clinical parameters (temperature, oxygen saturation, oxygen saturation to fraction of inspired oxygen ratio, cough, dyspnea, respiratory rate, thoracoabdominal dynamics) are indicated daily [18].

1.
A comprehensive assessment to evaluate the effect of long-term immobilizations such as ICU-acquired weakness, deconditioning, ICU polyneuromyopathy, pulmonary dysfunction.

Assessment of quality of life using Health-Related Quality of Life Assessment and Interventions [51].
3. Assessment of posture [52] and musculoskeletal assessment using Extra Short Musculoskeletal Function Assessment [53].
Physiotherapy Intervention should include limb exercises and peripheral muscle training through individual and/or group sessions. Interventions can also be provided virtually through telephonebased health coaching, use of apps to structure exercise programs and report on progress [54,55].

Notes Funding
This study did not receive financial support from external sources

Conflicts of interest disclosure
The authors declare no competing interests relevant to the content of this study.

Authors' contributions.
All the authors declare to have made substantial contributions to the conception, or design, or acquisition, or analysis, or interpretation of data; and drafting the work or revising it critically for important intellectual content; and to approve the version to be published.

Availability of data and responsibility for the results
All the authors declare to have had full access to the available data and they assume full responsibility for the integrity of these results.