COVID-19 pandemic has created a complex scenario. It is spreading rapidly and infecting individuals globally, leading to various types of complications and functional impairments after recovery. In addition to the disease itself, prolonged hospitalization of COVID patients causes many deleterious effects, such as pulmonary, cardiovascular, muscle, and cognitive changes, as well as depression and anxiety. A severe form of this disease causes respiratory failure, as a result of lung injury repair. Patients who recover from COVID-19 should undergo pulmonary rehabilitation during and after hospitalization, to reverse the adverse effects of the disease. Pulmonary rehabilitation of such patients is conducted by a multidisciplinary team because of the multi-systemic impairment caused by COVID-19. The team consists of medical professionals who work together to improve the functionality of the patient. A physiotherapist is also a part of this team. Physiotherapy rehabilitation helps the individual to improve his function and ability to perform activities of daily living thus improving his professional performance, and social interaction.

Physical therapist is among the most vulnerable medical professionals, as they work in close contact with the patients. Therefore appropriate Personal protective equipment (PPE) should be used following the guidelines given below.

·         Pulmonary Rehabilitation interventions should not be given to critically ill patients if there are signs of progressive deterioration until they become medically stable.

·         The patient  suffering from mild pneumonia, pneumonia without a productive cough, acute respiratory distress syndrome (ARDS), or asymptomatic COVID-19 should not be given breathing exercise.

·         For patients in isolation, rehab should be conducted through educational videos, instruction manuals educational videos.

·         Close monitoring  for patients with or without the use of mechanical ventilation should be performed throughout the rehab process to check the exercise-induced symptoms.. Vital signs (before, during, and after exercise) should be also monitored.

Physiotherapy techniques used for Pulmonary Rehabilitation should include

After assuring that the patient is medically stable to participate in therapies. The patient undergoes examination, physical therapist decides what treatment is to be given, and the appropriate treatment program is set, keeping a track of the patient’s treatment record and the condition of the patient.

 

Deep breathing

Deep breathing exercise is an important component of pulmonary Rehabilitation. Pulmonary rehabilitation depends on the coordination between diaphragm- strength, joint ROM, trunk-limb posture, balance, and change of posture which helps to improve oxygenation.

 

·         In-patient, (without ventilation support but require oxygen therapy) - Patient should be taught breathing exercises i.e slow inhalation and exhalation through the nose and mouth, pursed-lip & diaphragmatic breathing, and peripheral muscle training. Breathing exercises should be done twice a day, for 15 to 45 mins.

·       In-patient program for an intubated patient -  Patient should be taught breathing exercises  i.e coughing and huffing,  postural drainage should be done in a gravity-assisted position like prone positioning for acute respiratory distress syndrome (ARDS), open suctions, naso and oropharyngeal suctioning, sputum inductions should be performed in a negative pressure room or a closed-door single-room.

·    In-patient program, (extubated and before hospital discharge) Breathing exercises include - slow inhalation through the nose and slow exhalation through the mouth, pursed-lip & diaphragmatic breathing, and peripheral muscle training.

·   Out-patient program (after discharge from hospital and within a community) - Patient should be taught intentional breathing exercise, huffing, airway clearance techniques, posture management to adjust breathing rhythm,  thoracic expansion training, mobilization of respiratory muscle groups.

Bronchial hygiene techniques

Cleaning of airways at regular intervals is an important step for pulmonary rehab. Bronchial secretions may cause blockage of the airways resulting in difficulty in breathing. Although the cough is usually non-productive in COVID-19, productive coughing is observed at a later stage.

 

·         In-patient (without ventilation support but require oxygen therapy)  Bronchial hygiene is maintained by postural drainage, assisted cough, and percussion, clearance of secretion, cupping & huffing are the chest maneuvers used.

·         In-patient (extubated and before hospital discharge)  Bronchial hygiene techniques used are chest cupping, postural drainage with or without chest percussion, huffing is encouraged.

·         Out-patient (after discharge from hospital and within a community)  Airway clearance techniques used are (i ) Forced expiratory techniques to expel the sputum and reduce coughing and energy consumption, (ii ) Positive expiratory pressure to assist forced expiration.

Early mobilization

The prolonged ICU stay leads to the development of muscle weakness and decreased functionality. Functional assessment is done to evaluate the motor condition of the patient. Early mobilization includes posture change in upright, semi-sitting, forward-leaning depending on the patient's condition. Bed mobilization, bed-to-chair transfer, sit-to-stand training, assisted walking, and neuromuscular electrical stimulation in limb muscles,  quadriceps muscle function, walking capacity and proprioceptive neuromuscular facilitation.

 

Endurance training,

·         In-patient (without ventilation support but require oxygen therapy) Low-intensity exercise are recommended, bed mobilization, aerobic exercise, the patient is made to do active and passive joint ROM & stretching exercises, proper positioning with the use of pillow support in upright, semi-sitting, forward-leaning thrice a day, transfer to and from bed-chair, and NMES of limb muscles is done depending on the condition of the patient.

·         In-patient program (extubated and before hospital discharge) Aerobic exercise, joint ROM & stretching, posture change in upright, semi-sitting, forward-leaning, ADL training, transfer to and from bed-chair, balance training, resume slow-paced ambulation, & NMES for limb muscles. All these exercises are made to do depending on the patient's condition.

·         Out-patient program (after discharge from hospital and within a community) Once the patient is discharged from the hospital, the patient should start doing muscle-strengthening exercises by resistance training -  the patient should start with a reduced load and repeat it 8-12 times, 1-3 times a day, with 2-min rest in between the sets, 2-3 sessions per week for 6 weeks. Load should be increased around 5 to 10% each week, the patient should also do balance exercises to improve balance. Aerobic exercises  Like individualized walking, brisk walking, slow jogging, and swimming programs should be started with low intensity, for a short duration, 3-5 sessions per week, each session should last for 20 - 30 min. For ADL basic ADL guidance is provided to the patient with rehabilitation for bed mobility, transfer, ambulation, dressing, toileting, and bathing.

Patient and caregiver education plays an essential role, smoking cessation, peripheral muscle training, bronchial hygiene, adequate nutrition, healthy mind, oxygen therapy is important in improving lung function.

·        As COVID-19 pandemic is on a rise, the need of the hour is to adopt safety measures. Knowing that prevention is always better than cure, precautionary measures should be strictly followed such as hand washing at frequent intervals, wearing masks in public places, maintaining social distancing. But unfortunately, it is being observed that there are still many individuals who do not follow the safety measures, hence, not only putting themselves at risk but also the society as a whole.