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Physical Therapy Considerations of Neurologic Presentations in COVID-19

Hosts

Kim Levenhagen, PT, DPT, WCC, CLT, FNAP

Sharon L. Gorman, PT, DPTSc

PresentersAkanshka Verma, PT, MA, NCS

Sowmya Kumble, PT, MPT, NCS

Morgan Lopker, PT, DPT

Sponsors

Objectives • Recall a brief overview of the pathophysiology of COVID-19 as it

relates to the neurologic system• Discuss emerging evidence related to neurologic impairments found

in patients diagnosed with COVID-19• Consider the importance of vital sign monitoring when working with

neurologic patients with this condition• Review assessment of delirium, weakness and other impairments

found in this population• Discuss treatment strategies

Neurologic Implications of COVID-19 PathophysiologyVital Signs and Hemodynamics

Presented by Morgan Lopker PT, DPT

Senior Physical Therapist, Critical Care and Education LeadLos Robles Regional Medical Center Thousand Oaks, CA

Vice-Chair of the Academy of Acute Care Physical Therapy Practice Committee

Proposed COVID-19 Staging

Siddiqu 2020

Neurologic Sequela of Sepsis

Sonneville 2013

.

From Delirium to Dementia

Chung 2020

Olfactory Nerve Entry Point for COVID-19

Wu 2020

Pathways of Potential Virus Associated Neurologic Injury and Impairment

Wu 2020

ACE2 Receptor Mediated COVID -19 Neurologic Injury

Baig. 2020.

Cytokine Storm to Coagulation Cascade

Zhou 2020, Lippi 2020

Cerebral Hemodynamics

Bouzat 2013, Silvio Taccone 2013, Wilson 2016

Factors Affecting Cerebral Blood Flow and Intracranial Pressure

Bouzat 2013. Silvio Taccone 2013, Wilson 2016

Persistence of COVID -19 Neurologic Sequela

Chung. 2020

References • Baig AM, Khaleeq A, Ali U, Syeda H. Evidence of the COVID-19 Virus Targeting the CNS: Tissue Distribution, Host-Virus Interaction,

and Proposed Neurotropic Mechanisms. ACS Chem Neurosci. 2020:0-3. doi:10.1021/acschemneuro.0c00122• Bouzat, P., Sala, N., Payen, J. et al. Beyond intracranial pressure: optimization of cerebral blood flow, oxygen, and substrate delivery

after traumatic brain injury. Ann. Intensive Care 3, 23 (2013). https://doi.org/10.1186/2110-5820-3-23• Chung H-Y, Wickel J, Brunkhorst FM, Geis C. Sepsis-Associated Encephalopathy: From Delirium to Dementia? J Clin Med.

2020;9(3):703. • Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A

meta-analysis. Clin Chim Acta. 2020;506(March):145-148. doi:10.1016/j.cca.2020.03.022• Siddiqu HK, Mehra MR. COVID-19 Illness in Native and Immunosuppressed States: A ClinicalTherapeutic Staging Proposal. Journal

of Heart and Lung Transplantation. doi: 10.1016/j.healun.2020.03.012 • Silvio Taccone F, Scolletta S, Franchi F, Donadello K, Oddo M. Brain Perfusion In Sepsis. Curr Vasc Pharmacol. 2013;11(2):170-186.

doi:10.2174/157016113805290263• Sonneville R, Verdonk F, Rauturier C, et al. Understanding brain dysfunction in sepsis. Ann Intensive Care. 2013;3(1):1-11.

doi:10.1186/2110-5820-3-15• Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. J Cereb

Blood Flow Metab. 2016;36(8):1338–1350. doi:10.1177/0271678X16648711• Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun.

2020;(March):1-5. doi:10.1016/j.bbi.2020.03.031• Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a

retrospective cohort study. Lancet. 2020;395(10229):1054-1062. doi:10.1016/S0140-6736(20)30566-3

STREAMLINING YOUR ASSESSMENT FOR COVID -19 PATIENTS Sowmya Kumble, PT, MPT, NCS Clinical Resource Analyst Johns Hopkins Hospital

• Chart review • Medications• Assessment of cognition • Cranial Nerve Exam• Vital signs• Neuromuscular/ Musculoskeletal System • Integumentary system

Chart review • Co-morbidities (old stroke, any other NM disorders, seizures, dementia,

psychiatric, HTN, DM)

• Baseline functional status

• Lab values (troponins, D-dimer)

• Orders – O2 titration

• Imaging (CT/MRI brain)/EEG reports if done

• Medications – CNS side effects of sedation/paralytics

Medications • Sedative-analgesics

– Benzodiazepines (Midazolam)– Opioid analgesics (Fentanyl/Propofol) – Antipsychotics (Haloperidol) – α2-adrenoceptor agonists – Dexmedetomidine (Precedex)

• Neuromuscular blocking agents – Vecuronium

• Vasopressors (if <60 mmHg of MAP) – Norepinephrine(Levophed)

• Inotropes w/ vasodilator effect– Dobutamine

Cognition • Beyond AOx3• Arousal

– Richmond Agitation Sedation Scale (RASS)

• Speech/Communication • Safety awareness

+4 Combative +3 Very Agitated+2 Agitated+1 Restless0 Calm and Alert-1 Drowsy; eye opening & contact ≥

10 secs-2 Light sedation; eye open &

contact < 10 sec-3 Moderate sedation (Movement or

eye opening to voice; no eye contact)

-4 Deep sedation; no response to voice, eye open to physical stimulation

-5 Unarousable

RASS Score

Delirium“Disturbance in consciousness and cognition that develops over a short period of time (eg, hours to days) and tends to fluctuate during the course of the day”

• Risk factors – Predisposing factors (baseline)– Precipitation factors (hospitalization –related)

The American Psychological Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV

Risk factors for Delirium

AgeHTN

Pre-existing cognitive deficit/Dementia

Alcohol use Depression

Severity of illness Respiratory disease Need for mechanical

ventilation Medications (sedatives –

Benzos; opiates)Hypotension

Sepsis Fever

Lack of daylight Isolation

Lack of visitorsImmobility

Sleep deprivation

ICU Delirium - Screening• Screening tools:

– Confusion Assessment Method (CAM)- ICU– Intensive Care Delirium Screening Checklist (ICDSC)

1. Acute change or fluctuating course of mental status over the past 24 hours

2. Inattention:Squeeze my hand when I say the letter ‘A’SAVE A HAART

3. Altered level of consciousness (Current RASS)

4. Disorganized thinking: 1. Will a stone float on water?2. Are there fish in the sea?3. Does one pound weigh more than two 4. Can you use a hammer to pound a nail?

YES

>2 errors

RASS = 0>1 error

CAM-ICU positive Delirium present

RASS ≠ 0

CAM-ICU

www.icudelirium.org

Types of Delirium • Hypoactive

– Lethargic/drowsy/infrequent spontaneous movement• Hyperactive

– Agitated/combative/risk for self-extubation/falls/line dislodgment• Mixed

Cranial nerves • CN I – Smell • CN II – Asymmetrical pupil size; reaction to light) • CN III, IV, VI- Oculomotor (eye movements) • CN V - Facial sensation, if awake and oriented • CN VII- Facial movements/sensation of tongue• CN VIII- Vestibular/ hearing • CN IX and X - taste/hoarseness of voice• CN XI – shoulder shrug (Trapezius) & head rotation (SCM) • CN XII – Tongue movement

Vital Signs • Breathing pattern

• Accessory muscle use

• O2 saturation /O2 requirement

• Blood pressure (Mean arterial pressure)

• Heart rate (Tachycardic PE)

• EKG abnormalities

• RPE scale, if alert/oriented

Neuromuscular/Musculoskeletal• Observation - Abnormal posture/positioning

– foot drop /shoulder subluxation• Tone • ROM • Muscle strength (Brachial Plexus Injuries/PNI/ ICU acquired

weakness/Stroke/Guillain-Barré Syndrome):– Symmetrical vs Asymmetrical– Proximal vs Distal – UE vs LE

• Sensation – Touch/Proprioception• Coordination • Balance – static/dynamic/ functional

Integumentary System • Positioning

– Prone• Pressure relief

Functional mobility & hemodynamic stability• Positional changes

– Raising the head of bed gradually– Continuous monitoring for tolerance to position change

• O2 saturation – time to recover– additional O2 needs to recover (Titrate as needed if ordered)

http://cardiopt.org/pdf/pubs/Supplemental_Oxygen.pdf

Take Home Messages• Oxygenation & perfusion is vital for brain function

– PT role in early detection of neurological manifestations

• Adverse effect of prone positioning

– Screen for peripheral nerve injuries

• As much info in very little contact time

• COVID-19 is NOT JUST a pulmonary condition

– “Patient as a whole”

PT Management of Patients with

COVID-19 Akanshka Verma, PT MA

NCS

REHAB MANAGEMENT OF COVID-19 patients

Goals of a rehab program:

● reducing the complications associated with a prolonged ICU stay● improving tolerance to activity● improve cognitive and emotional domains, in order to

○ promote the quality of life and ○ facilitate home discharge

REHAB MANAGEMENT OF COVID-19 patients

● Acute ICU phase ○ Assistance with proning to improve oxygenation

○ Prevention of skin breakdown

○ Management of ICU delirium/ encephalopathic changes/CNS changes due to metabolic disarray

○ Management of cognitive changes

Importance of diagnosing and managing ICU delirium● Delirium is defined as a disturbance of consciousness, with inattention accompanied by a change in cognition or

perceptual disturbance that develops over a short period (hours or days) and fluctuates over time.

● 60-80 percent of ICU patients on mechanical ventilation experience delirium

● One in three patients with ARDS experiences PTSD a year after the medical event● Assessment of delirium

Confusion assessment method for ICU- CAM

Factors that increase risk of delirium● HTN● Smoking● Pre Existing dementia● Obesity● Precipitating factors are hypoxia, metabolic disturbances, withdrawal syndromes, dehydration, and

medications.○ Loss of sleep awake cycles, sleep deprivation, excessive noise, lighting

https://ohiohospitals.org/OHA/media/OHA-Media/Documents/Patient%20Safety%20and%20Quality/Hospital%20Improvement%20Innovation%20Network/Additional%20Topics/Iatrogenic%20Delirium/1-24-19-MHA-and-OHA-Learning-Network.pdf

Management of Post ICU DeliriumABCDEF (A2F) bundle

COMPONENT

A Assessment & Management of pain

B Spontaneous Awakening trial & Spontaneous Breathing trial

C Choice of analgesia & sedation

D Delirium: assess, prevent & manage

E Early mobility & exercise

F Family engagement & empowerment

Management of Post ICU Delirium

● Management must be specific to Patient population

● Repeated reorientation of patients

● Provision of cognitively stimulating activities

● ROM exercises

● Early mobilization with caution

● Timely removal of noxious factors- restraints, catheters

● Delirium specific multidisciplinary education of staff

ICU delirium [Internet]. Nashville, VUMC Center for Health Services Research. c2013; [accessed on 8 Aug 2016]. Available from: www.ICUdelirium.org.

REHAB MANAGEMENT OF COVID-19 patients

Acute non-critical care management:

● Closely monitor for worsening of respiratory status & orthostatic changes

● Low intensity, interval training

● Outcome measures

● Cognition

● Subjective measures of fatigability

Modified rate of perceived exertion

https://thefittutor.com/rpe-scale/https://www.cdc.gov/physicalactivity/basics/measuring/exertion.htm

REHAB MANAGEMENT OF COVID-19 patients

The rehab phase ● Understanding of patient specific impairments & activity limitations

● Aerobic exercise: for those cases with respiratory/motor problems and physical deconditioning,- incorporate functional tasks

● Strength training for peripheral muscle weakness

● Static and dynamic balance training for balance dysfunction

● Neuropsychological training: counselling sessions, psychological support, and cognitive training.

REHAB MANAGEMENT OF COVID-19 patientsExercise Prescription

· Modeo Self-care and functional trainingo Aerobic – postural change, supervised ambulationo Breathing with overhead activities.· ★ Pair inhalation and exhalation patterns with movt to enhance the motor task and improve

oxygenation· Intensity

o Consider using RPEo Correspond SpO2 ratings with RPE scale in order to be independent with pacingDurationo Begin with intermittent bouts lasting 3-5 minutes as toleratedo Rest periods at patients’ discretion

Aim for shorter rest than exercise – 2:1 ratio· Frequency

o Consider all disciplines that interact with patients

REHAB MANAGEMENT OF COVID-19 patients

Patient Education

❖ · Instruct to watch for signs of hypoxemia at home

❖ · Energy conservation techniques

❖ · Walking program

❖ · Field questions as you are able re: diagnosis and disease progression

❖ · Handouts

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