26 March 2020

Patients who have been infected with the coronavirus and admitted to the hospital for this reason should receive physiotherapy as soon as their condition allows. Seriously ill patients who are on ventilators and are confined to a hospital bed for long periods experience problems with breathing and other physical issues, due to their protracted inactivity. Physiotherapists can be of great value to patients and their care in this regard. This is the view expressed by physiotherapists and researchers from the Radboudumc in a set of joint treatment recommendations.

In the current crisis period, it is easy to assign low priority to the long-term effects of hospital admission on patients with the coronavirus. As the literature on the SARS outbreak in 2003 has taught us, however, this had major consequences for the organization of rehabilitation care in the countries that were most affected by that epidemic. Healthcare systems were not sufficiently prepared to provide adequate treatment for the long-term consequences of SARS. Given the large numbers of patients with the coronavirus in intensive care units in the Netherlands, we can also expect an increase in the number of patients needing rehabilitation following admission to an intensive-care unit. It is therefore important to address this issue promptly.

For this reason, the researchers—including Karin Felten-Barentsz and Thomas Hoogeboom —have compiled a set of national treatment recommendations, distinguishing four phases of treatment. Prompt preparation for the influx of large numbers of patients is important.

Phase 1: Patient in the intensive-care unit receiving ventilation in the prone position

No treatment is provided in this phase, due to the scarcity of personal protective equipment and the risk of virus transmission. Although patients lose a great deal of muscle mass in this phase, the risk of contractures (the shortening of muscles or tendons, leading to limitations in motion) is low. Nurses could possibly exercise the joints passively.

Phase 2: Patient in the intensive-care unit whose condition has improved

In this phase, the patient is recovering. The patient is eligible for physical therapy to promote early mobilization and activation, but is not yet disconnected from the ventilator. It is obviously important to observe infection-prevention measures.

Phase 3: Recovery after intensive care

At first, patients in this group have little energy. People on bed rest for the entire day lose about 5% of their total muscle mass and general condition each day. These patients are given exercises aimed at improving lung function by strengthening the respiratory muscles, coughing up phlegm more effectively and breathing more deeply, thereby improving the ventilation of the lungs. They are also given motion exercises. Whenever possible, this is done through pamphlets, online videos and telerehabilitation.

Phase 4: Follow-up program

Patients who have been seriously ill need intensive rehabilitation care, even after they have been discharged from the hospital. Following intensive-care treatment, patients may experience respiratory problems resulting from long-term physical inactivity due to illness. This condition is known as “post-intensive care syndrome” (PICS). Recovery can take months, or even years, and proper guidance is needed.

These recommendations have been endorsed by the Royal Dutch Society for Physiotherapy (KNGF), the Dutch Association of Physical Therapy in Hospitals (NVZF), and the Dutch Society of Intensive Care (NVIC). The treatment recommendations were compiled by Radboudumc researchers from the Paramedical Sciences research group, within the Departments of Rehabilitation and IQ Healthcare: physiotherapists Karin Felten-Barentsz, Roel van Oorsouw, Emily Klooster and Niek Koenders—all of whom are specialized in intensive care and/or cardiopulmonary physical therapy—and researchers Thomas Hoogeboom and Philip van der Wees.
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