Michelle Kho, PT, PhDMcMaster UniversitySchool of Rehabilitation ScienceCanada Research Chair in Critical Care Rehabilitation and Knowledge Translation

6 April 2021

Understanding the COVID-19 patient:Acute care to long term recovery

Objectives:1. To provide home and community care PTs and PTAs with a

clinical presentation of COVID-19 patients who are:• Critically ill in ICU• Hospitalized in acute care, and• Those who are managed directly within the community without

requiring hospitalization

2. Describe “persistent/residual symptoms” in those recovering from COVID-19

3. Offer ideas about home and community rehab needs for those with persistent/residual symptoms

Session Objectives

Land Acknowledgement

McMaster University recognizes and acknowledges that it is located on the traditional territories of the Mississauga and Haudenosaunee nations, and within the lands protected by the “Dish with One Spoon” wampum agreement.

Needham et al., Crit Care Med 2012 Vol. 40, No. 2

Post-Intensive Care Syndrome (PICS)

Rousseau et al. Crit Care (2021) 25:108.

ICU-Acquired Weakness

ICU conditions• Sepsis• Multi-Organ failure• Acute respiratory distress syndrome• Systemic inflammation

Metabolic• Hypoglycemia

Critical illness polyneuropathy / Critical illness myopathyCritical illness neuromyopathy

Baseline factors• ↑Age• Female Sex• Frailty• Comorbidity

ICU interventions• Mechanical ventilation• Sedation• Neuromuscular blockers• Corticosteroids

Muscle atrophy

Delirium

Immobility/ bed rest

• Severe muscle atrophy• Preferential myosin loss• Sarcomere disorganization• Hypoexcitability

5 tips for patient-centred rehabilitation with COVID-19 survivors1. Remember the basics2. Consider patient-important outcomes3. Consider shoulder involvement4. Start with low-intensity activity5. Consider the whole person and family

1. REMEMBER THE BASICS

MACE – Major Acute Cardiac Event(heart failure, MI, stroke or arrhythmia)

BMJ 2021;372:n693.

Rehabilitation Implications:Diabetes: glycemic control, risk of future neuropathy, retinopathyMACE: carefully monitor heart rate, blood pressure

2. CONSIDER PATIENT-IMPORTANT OUTCOMES

Emerging evidence in COVID-19

RCTs

Cohort studies

Case control

Case series

Pre-prints, Case Reports, Biological rationale

News reports, press releases

↓ Bias

↑ Bias

Study design Core Outcomes

Tong et al., Critical Care Medicine, 2020. DOI: 10.1097/CCM.0000000000004585Adapted from CMAJ. 1981. 24: 985-990.

Synthesis

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Measuring shortness of breath:Modified Borg Scale for Dyspnea

International Journal of COPD 2012:7 345–355.

3. CONSIDER SHOULDER INVOLVEMENT

Prone positioning in COVID-19

Prone positioning accompanied by:• Invasive ventilation• Deep sedation• Neuromuscular blockers

Risks include:• Brachial plexus injuries• Pressure ulcers• Joint contractures

Clinical tips:• Patient history of ICU or hospital stay• Conduct shoulder assessment

https://www.cbc.ca/radio/day6/icus-in-crisis-beyond-the-chauvin-trial-unionizing-amazon-china-s-digital-currency-depresh-mode-and-more-1.5973360/situation-in-ontario-icus-like-a-never-ending-fire-amid-covid-19-3rd-wave-says-nurse-1.5973374

Sakelliariou et al., ISRN Orthopedics. Volume 2014, Article ID 726103

Early research: Ulnar nerve injury most common in patients proned in ICUNerve roots: C8, T1Muscles: Flexor carpi ulnaris; intrinsic muscles of handTest: Wrist/ finger flexion; finger abductionFurther MSK PT input may be needed

Miller C et al., Brachial Plexus Neuropathies During the COVID-19 Pandemic: A Retrospective Case Series of 15 Patients in Critical Care. Phys Ther 2021; 101.

4. START WITH LOW-INTENSITY ACTIVITY

Salman et al., BMJ 2021;372:m4721

Continuum of physical activity

https://sites.google.com/site/compendiumofphysicalactivities/

< 1.5 METS

1.0 1.5

Vigorous >6

9.8 10.08.0 23.0

Moderate 3-6

3.5 5.02.0

Light <3

2.5

> 1.5 METS

PT761 McMaster University | M Kho PT PhD

Get the guidelines here: https://csepguidelines.ca/adults-18-64/

Ross et al., Applied Physiology, Nutrition, and Metabolism. 45(10 (Suppl. 2)): S57-S102. https://doi.org/10.1139/apnm-2020-0467

Physical activity contributes to mental health and wellness

Learn more at csepguidelines.ca

5. CONSIDER ADDITIONAL FACTORS

• Heterogeneous disease states

• Varied health trajectories

Extreme illness

Advanced life support in distinct hospital location

New or worsened medical complexity and multimorbidity

Herridge. Am J Respir Crit Care Med. 2017. 196(11). 1380–1384.1 Herridge et al., Am J Respir Crit Care Med 2016;194(7) 831–844.2 Pandharipande et al., N Engl J Med 2013;369:1306-16.3 Cameron et al., N Engl J Med 2016;374:1831-41.

40% unable to walk @ 7 days post-ICU1

1 year: 20% severe PTSD; 20% severe depression1

3 months: 66% global cognition scores worse than TBI2

3 months: 49% depressive symptoms3

• Heterogeneous disease states

• Varied health trajectories

Extreme illness

Advanced life support in distinct hospital location

New or worsened medical complexity and multimorbidity

Herridge. Am J Respir Crit Care Med. 2017. 196(11). 1380–1384.1 Herridge et al., Am J Respir Crit Care Med 2016;194(7) 831–844.2 Pandharipande et al., N Engl J Med 2013;369:1306-16.3 Cameron et al., N Engl J Med 2016;374:1831-41.

40% unable to walk @ 7 days post-ICU1

1 year: 20% severe PTSD; 20% severe depression1

3 months: 66% global cognition scores worse than TBI2

3 months: 49% depressive symptoms3

5 tips for patient-centred rehabilitation with COVID-19 survivors1. Remember the basics2. Consider patient-important outcomes3. Consider shoulder involvement4. Start with low-intensity activity5. Consider the whole person and family

Thank you!Michelle Kho, PT PhDkhome@mcmaster.ca @khome