Video Call-based strategically Planned Physiotherapy Management of Middle-aged Male Adult with Postacute Sequelae of COVID-19: A Case Report
Corresponding Author: Madhura R Patil, Physiotherapy School and Center, Topiwala National Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India, Phone: +91 8425958871, e-mail: firstname.lastname@example.org
Received on: 01 September 2022; Accepted on: 05 December 2022; Published on: 14 March 2023
Introduction: Video call-based physiotherapy management has been recommended in the Coronavirus disease 2019 (COVID-19) pandemic to limit the spread of infection between patients and physiotherapist.Case description: We present a 55-year-old diabetic male who needed invasive ventilation for 2 weeks after being diagnosed with COVID-19 with severe acute respiratory distress syndrome (ARDS), COVID-19-induced diabetic ketoacidosis, and metabolic encephalopathy. At discharge on day 28, he had breathlessness in activity of daily living (ADL), fatigue, swelling with tingling in both lower limbs (LL), difficulty in getting up from a chair, and maintaining balance. Rehabilitation was started 2 days after discharge for 9 weeks and included counseling, breathing exercises, and exercises to improve strength, balance, and mobility.Results: The perception of fatigue and functional independence improved by 40 and 57%, and the 6-minute walk distance (6MWT) and 1-minute sit to stand (1 MSTS) improved by 61 and 90%, respectively. Conclusion: The structured implementation of physiotherapy management made the patient fully functional in his work by 5 months post-discharge.
How to cite this article: Verma CV, Patil MR, Karnik ND, et al. Video Call-based strategically Planned Physiotherapy Management of Middle-aged Male Adult with Postacute Sequelae of COVID-19: A Case Report. Indian J Respir Care 2023;12(1):96-99.
Source of support: Nil
Conflict of interest: None
Keywords: Activity of daily living, Coronavirus disease 2019, Diabetic ketoacidosis, Video call-based physiotherapy.
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus SARS-CoV2 virus. It mainly spreads through respiratory droplets through close contact. COVID-19 commonly presents with mild symptoms of fever, dyspnea, and dry cough which may culminate into severe symptoms of hypoxia and acute respiratory distress syndrome (ARDS) needing oxygen therapy, high flow nasal cannula, noninvasive ventilation, and even invasive mechanical ventilation, which affects overall functional capacity.1 The clinical course is often complicated by severe uncontrolled sugar levels, diabetic ketoacidosis, and thromboembolic complications, including pulmonary thromboembolism, cerebrovascular accidents, and acute coronary syndrome. Survivors often need long-term hospitalization and experience a decrease in functional capacity, which causes impaired balance and deterioration in muscle strength and quality of life.2
Evidence has shown that postdischarge home isolation has led to the continuation of physical deconditioning at the musculoskeletal and metabolic levels.3 Physical activity programs have reported beneficial effects in maintaining muscle mass and strength and preventing metabolic and nutritional decompensations caused by inactivity. Due to the contagious nature of COVID-19, video call-based physiotherapy has been recommended to limit the spread of infection between the patient and the physiotherapist.4
Video call-based physiotherapy is the delivery of rehabilitation services via information and communication technologies and includes evaluation, assessment, monitoring, prevention, intervention, supervision, education, consultation, and coaching. It has been viewed as an electronic personal protective device in the COVID-19 pandemic.4 It is a holistic program aimed to help those patients who have recovered from COVID-19 to regain their physical activity levels, improve their quality of life, and most importantly, cope better with the emotional and psychosocial impact of the disease.
This case report highlights the successful implementation of a video call-based rehabilitation program in critically ill COVID-19 patients who needed invasive mechanical ventilation with prolonged intensive care unit (ICU) stay.
A 55-year-old known diabetic tested positive for COVID-19, residing 60 km away from a dedicated COVID-19 tertiary care hospital in Mumbai, needed ICU care on the 7th day after two episodes of convulsions. He was in a diabetic ketoacidotic coma, had metabolic encephalopathy, and needed invasive ventilation for COVID-19 ARDS. He regained sensorium after 10 days, was extubated on day 14, and was kept on 10 L of oxygen with a non-rebreathing mask. The patient received remdesivir, tocilizumab, intravenous insulin, dexamethasone, and heparin in standard recommended doses. He was discharged from the medical ICU on day 28 on room air after testing negative for COVID-19 under medical supervision. At home, the patient had the following residual symptoms of breathlessness on walking a few steps, fatigue, swelling in both legs, and required assistance in getting up from a chair and standing. He was referred for physiotherapy management after 2 days following discharge. Written (scanned signature) and audio consent for participation was taken from the patient prior to commencing pro bono daily rehabilitation sessions.
Video call-based physiotherapy sessions were conducted using Zoom app video calling in the presence of a caregiver. A secondary method of contact (telephone call) was arranged in case of technical issues. Rehabilitation sessions were conducted by a cardiopulmonary physiotherapist, and patient assessment and prognosis were documented daily for 9 weeks (30–45 minute/session) from the month of September to November.
Baseline assessment included the history of the present illness, medical management, assessment of vitals by the caregiver, and basic cardiopulmonary assessment by a physiotherapist (Table 3). In addition to the assessment, the following outcome measures—6MWT, 1-minute step test, Timed Up and Go (TUG), Fatigue Severity Scale (FSS), Functional Independence Measure (FIM), and Berg Balance Scale (BBS) were assessed at baseline.5
|Week||Type of exercises||Repetition||Days/week|
|0–3||Relaxation—guided imagery||20 minutes two times/day||7 days|
|Breathing exercises—thoracic expansion, purse lip breathing, diaphragmatic breathing, and segmental breathing||10 repetition three times a day||7 days|
|Mobility exercises of UL and LL||10 repetition three times a day||4–5 days|
|UL strengthening with 0.5 kg weight||10 repetition three times a day||4–5 days|
|3–6||UL strengthening with 1 kg weight and LL with 0.5 kg weight
Balance training, stepping (3-inch stepper), and STS
|10 repetition three times a day||4–5 days|
|Walking||Three times a day||7 days|
|6–9||UL strengthening with 1.5 kg weight and LL with 1 kg weight and progressing to 1.5–2 kg weight
Stepping (6-inch stepper) and core muscle strengthening
|10 repetition three times a day||4–5 days|
|Stair climbing with support and walking||Three times a day||7 days|
|Jogging, cycling, and running||one to two times||3–4 days|
LL, lower limb; UL, upper limb; STS, sit to stand
|Test||Week 1||Week 3||Week 6||Week 9|
|6 MWD (meters)||85||205||380||467|
|1 MSTS (count)||2||18||32||38|
|FIM (Total 126)||106||119||124||126|
|BBS (Total 56)||30||47||52||54|
6MWD, 6-minute walk distance; 1 MSTS, 1-minute sit to stand; BBS, Berg Balance Scale; FSS, Fatigue Severity Scale; FIM, Functional Independent Measures; TUG, Time Up and Go test
|Structure affected||Clinical reasoning|
|X-ray—shows B/L resolving patchy ground glass opacities in middle and lower lobes||Diffuse alveolar damage with cellular exudates and infiltrates formation causing desquamation of pneumocytes leading to ground glass opacities|
|High-resolution computed tomography—few ground glass opacities seen involving B/L lung parenchyma mainly in peripherals B/L mild pleural effusion||Inflammation due to cytokine storm causes damage to the alveolar cell and pneumatocele, leading to the accumulation of fluid in alveoli|
|Functions affected||Clinical reasoning|
|Breathlessness on walking (grade III)||Due to infiltrates, the alveoli diffusion is affected, which causes hypoxia|
|B/L pedal edema||Prolonged immobilization causing fluid to buildup|
|LL weakness (difficulty to perform STS)||Due to distortion of protein to deoxyribonucleic acid ratio and muscle protein synthesis, along with prolonged immobilization, causes a decrease in muscle mass and increased muscle catabolism leading to muscle weakness|
|Balance affected (one leg stance)||Due to prolonged immobilization and muscular weakness|
|Fatigue||Due to cytokine storm and reduction in peripheral oxygen supply|
|Inability to perform self-care activities (dressing of LL)||Performed with the assistance of relative|
|Unable to get up from the chair||Performed with the help of a walker|
|Difficulty in walking||Performed with the help of a walker|
|Difficulty in maintaining balance while walking||Performed with the help of a walker|
|Difficulty in performing toilet transfers||Performed with the assistance of relative|
|Unable to perform his daily routine recreation and leisure activities||Unable to continue his job|
|Patient cooperative and compliant||Diabetes mellitus and||Row house (separate room for isolation)||Staircase inside house|
|Awareness about the condition||Hypertension||Hospital away from home|
B/L, bilateral; LL, lower limb; STS, sit to stand
During all sessions of rehabilitation, his daughter was present and assisted in the delivery of exercises to ensure patient safety during the session.
Physiotherapy intervention was planned based on the International Classification of Functioning (ICF) assessment; specific, measurable, achievable, relevant, and time-bound goals were formed where the patient, caregiver, physiotherapist, and primary care physician were involved in decision-making. COVID-19 guidelines and American College of Sports Medicine (ACSM) guidelines for diabetes mellitus were referred for planning rehabilitation.3,6-8 Table 1 gives the detailed video-called based physiotherapy management program at weeks 0–2, 3–5, and 6–9.
The patient was prescribed a home exercise program thrice a day under the supervision of a caregiver with monitoring of vitals. The patient was assessed again at the end of week 1, 3, 6, and 5 on all outcome measures.
The results at week 1st, 3rd, 6th, and 9th are outlined in Table 2. The overall improvement in various parameters is given in Figure 1. The patient resumed work 5 months after discharge with controlled blood sugar levels and a full functional recovery.
In uncertain times and with the need for social distancing, the implementation of televideo call-based physiotherapy management has been considered an opportunity for the advancement of telehealth in managing COVID-19 patients. In the COVID-19 crisis, physiotherapy, along with medical management, has played a vital role.6,7,9,10 A study suggested that COVID-19 patients reported post-COVID-19 complications postdischarge, with 53% reporting fatigue, 43% breathlessness, and 27% joint pain. It is necessary to develop rehabilitation services to address the impact of COVID-19 in survivors.11,12 In recent years, video call-based physiotherapy management has been proven as an efficient treatment and patient evaluation practice for acute and chronic musculoskeletal, cardiac, neurological, and respiratory dysfunctions.13
This case report highlights the importance of video call-based physiotherapy rehabilitation in managing post-COVID-19 complications. A structured physiotherapy intervention has helped in improving his health status and making him functionally independent by being an integral part of the multidisciplinary team. In this case, physiotherapy management was implemented according with reference to COVID-19 physiotherapy guidelines published by our own institute and exercise prescription for diabetes mellitus given by ACSM.6-8 Target heart rate was calculated with Karvonen formula. Vitals were monitored during the sessions to ensure patient safety.4 Sessions started with patient education and guided imagery to induce relaxation, followed by mobility exercises of the upper and lower extremity, breathing exercises, balance training, strengthening exercises of the upper and lower extremity, gait training, and aerobic exercises with a moderate intensity, which were further progressed to vigorous intensity. The perception of fatigue and functional independence improved by 40 and 57%, respectively. The functional capacity assessed by 6MWT and 1 MSTS improved by 61 and 90%, respectively, which promoted general health and well-being (Table 3). Video call-based physiotherapy management was an effective medium of intervention for preventing post-COVID-19 complications during the quarantine period following discharge. Patient education played a vital role in implementing the same. A significant drawback faced by the therapist was connectivity issues which led to frequent delays in sessions. A better understanding by our patient and his family reinforced the positive outcome presented in this case. The patient’s education as well as financial status, along with the support provided by his family members, contributed to the success of physiotherapy services.
Video call-based physiotherapy management here has been proven to be an effective tool to provide personalized one-to-one care to a postventilator debilitated COVID-19 positive diabetic patient to the point of full functional recovery to return back to work.
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