Crucial role of physiotherapists in recovery on Covid-19 patients

By Rafe’aton Md Ali

KUALA LUMPUR: “Mama, I pray to Allah for your speedy recovery from Covid-19 each day. I hope and pray that you can come back soon and hug me. I don’t want you to die, adik loves you mama.”

These are the words of 7-year-old Nor Alisya Balqis Mohd Dazhuddin, who spoke amid tears, to her mother Noor Hazila Muhammad, 43, a stage three Covid-19 patient, who was quarantined for two weeks at the Covid-19 Quarantine and Treatment Centre (PKRC), Malaysia Agro Exposition Park Serdang (MAEPS), near here, last July.

It was her youngest daughter’s tears and cries at night that made her bounce back from the Covid-19 doldrums by learning techniques in regaining her strength and become mobile again, from physiotherapists who conduct visual lessons for Covid-19 patients.

Noor Hazila said, she was critically ill at the time when she was first quarantined at the PKRC MAEPS on July 18.  With a body mass index (BMI) of over 30, she is considered obese. Her conditions worsened as she has a history of asthma since she was three years old, coupled with a record of other chronic diseases such as diabetes and hypertension.

“I was very depressed after being diagnosed positive from Covid-19. Besides having symptoms such as fever and phlegm, my X-ray results indicate that my lungs have been badly infected, with signs of pneumonia,” she told Bernama.

She said, tests for pneumonia from her blood samples (C-reactive protein/CRP) gave an extremely high reading at 150mg/L compared to a normal individual’s reading of 10mg/L.

“I usually suffer from shortness of breath and extreme fatigue. I couldn’t walk to the bathroom, not even 10 metres away from my bed,” said Noor Hazila, who has not received her Covid-19 vaccine as she was allergic to certain medications.

“On my mind were only images of my husband and my children…it was the darkest moment in my life as it appeared that there was no glimmer of hope for me to recover from this Covid-19 infection,” said Noor Hazila, who works as an administrative assistant at a clinic at Hospital Canselor Tuanku Muhriz (HCTM), Universiti Kebangsaan Malaysia (UKM), Cheras.

Determined to exercise during quarantine

With the help of her friend, who is also a physiotherapist at HCTM, Noor Hazila gathered her strength by doing some simple exercises as frequently as possible through tele-physiotherapy during the quarantine period at MAEPS.

“Although I am prone to asthmatic attacks, I continued to work out, either while lying in bed, sitting down or standing. I usually sleep face-down on my stomach, or my left or right side,” she said, adding that the exercises helped her breathe easily,” she added.

Khairul Anuar. Photo courtesy of the National University of Malaysia (UKM)

Another Covid-19 patient, Khairul Anuar, 44, who has a history of chronic illnesses such as diabetes and hypertension, admitted that the workouts taught by the physiotherapist, helped him improve his breathing.

Khairul who was discharged from Selayang Hospital on Aug 29, said he made it a point to exercise daily after dawn and afternoon prayers.

“… I would usually lift my legs, sit by the bedside and take breathing exercises for 20 to 30 minutes,” he said, adding that after five days in quarantine at the hospital, he no longer needed oxygen support.

 “Now, both my wife (who is also Covid-19 positive) and myself, would continue with our daily exercises, even if it is only for 15 minutes,” said Khairul Anuar, who received his dose of vaccine on Aug 29.

Nazruddin Daud walks with the support of a forearm walker while in quarantine and receiving treatment at the intensive care unit (ICU). Photo courtesy of the National University of Malaysia (UKM)

Nazruddin Daud, 41, who is category 4 Covid-19 patient and received treatment at HCTM’s intensive care unit (ICU), said, the practice of sleeping face-down on his stomach or prone position, for more than four hours a day, helped boost the oxygen level in his body to over 90 per cent.

“At the same time, brisk walking for 20 to 30 minutes with the guidance of a physiotherapist using a forearm walker during treatment at the ICU, helped me recover fast and rebuild my energy,” said Khairul Anuar, who underwent sleeve gastrectomy on Aug 14.

The stories of suffering, despair and hope as shared by Noor Hazila, Khairul and Nazruddin, may also be experienced by thousands out of the 1,979,698 Covid-19 patients (as at Sept 12) in the country who undoubtedly need follow-up physiotherapy treatment after being discharged from the hospital.

Early intervention & rehabilitation of Covid-19 patients

Noor Hazila, previously infected with Covid-19, keeps to her inspirational muscle training schedule even after being discharged from the hospital. Photo courtesy of the National University of Malaysia (UKM)

HCTM’s Head of Covid-19 Physiotherapy Services Dr Katijjahbe Mohd Ali said, physiotherapists play a vital role in in the care and treatment of Covid-19 patients at either the normal ward or the ICU.

“Mobilisation not only helps to build up the ability to breathe deeply, but helps them rebuild their strength, mobility and balance, such as walking and getting dressed without any assistance while patients are in the hospital,” said the clinical physiotherapist.

She said about 40 to 50 per cent of Covid-19 patients would experience weak muscles and fatigue and some with extreme fatigue, while patients who are badly infected (categories 3 and 5), can experience fatigue, with an oxygen uptake of below 85 per cent, by just taking small steps. The normal oxygen level reading is between 95 to 100 per cent.

“As such, rehabilitation will be properly planned and will be conducted gradually so that the patient can move as quickly as possible to strengthen the muscle compared to patients who are sedentary,” she added.

Dr Katijjahbe said early mobilisation starts by asking the patient to move the hand, legs and body in bed, and gradually teach the patient to stand, marching on the spot and finally learn to stand, depending on the individual’s capability. 

“Through the guidance of physiotherapists, the patient usually manages to sit on the edge of the bed, using hoists to help the patient to sit upright in a chair and standing using a forearm walker or taking a few steps while still supported by a ventilator.

“At present, physiotherapists monitor the key indicators such as the oxygen level, respiratory level and blood pressure of the patient to ensure that any movement taken would be safe and efficient,” she said, adding that to avoid the patient from feeling tired, the therapy sessions will be shortened from half an hour to only 10 to 20 minutes and will be carried out more regularly.

According to Dr Katijjahbe, HCTM through the Physiotherapy Unit in collaboration with the Cardiology Unit, took the initiative to prepare a special pamphlet on Covid-19 patients who are still active with a slogan ‘Senaman Move it, Lawan Covid-19 #KITA MESTI MENANG’ which can be accessed by scanning the QR code.

Positioning, mucus & respiratory treatment

The self-awakening prone position helps boost the oxygen saturation levels of Covid-19 patients. Photo courtesy of the National University of Malaysia (UKM)

In the case of critical Covid-19 patients who are on respiratory support at the ICU, the therapy position such as the prone positioning or face-down on the stomach, is recommended for 16 to 18 hours to increase the oxygen uptake in their blood, said Dr Katijjahbe.

Hence, this scenario requires a team of four to five trained medical personnel including a physiotherapist to change the position of patients who are profoundly weak and unable to move their arms and legs,” she said.

She said for the patient who is on a non-invasive ventilator, it is recommended that he or she should be treated in their conscious state without any support, for two to eight hours a day.

“For the patient who has undergone surgery, lying on one side of the bed or in a flat position is also recommended, depending on the patient’s condition and whatever is comfortable, to help his or her lungs function better,” said Dr Katijjahbe.

She said manual, breathing and autogenic drainage techniques are also applied as studies show that 34 per cent of critically-ill patients are likely to face problems of excess mucus in their lungs and dry cough.

“Mucus secretions are formed probably after the patient is admitted to the ICU and the physiotherapist can reduce or clear the secretions through various techniques such as through manual therapy or by tapping the patient’s back to clear chest congestion and removing the mucus via the endotracheal tube (ET), which is linked to the ventilator.

Challenges of treating Covid-19 patients

Senior physiotherapist of the Ministry of Health Nur Hidayah Ong Abdullah said given that Covid-19 is a relatively new disease, physiotherapeutic treatment is expected to be more challenging.

“We find that delirium, an acute condition characterised by confusion and reduced awareness and cognitive issues, are relatively common among Covid-19 patients at the ICU. Under sedation, the patients are half conscious, but not asleep, hence causing them to be disoriented with the environment,” she said.

At the same time, Covid-19 patients also suffer from depression and anxiety especially when they are treated by healthcare frontliners, who are not easily recognised, as the latter are fully geared in their personal protective equipment (PPE), she noted.

“Other challenges include senior citizens and patients who are mute, obese, mental illness and stroke patients, as well as those with a history of comorbidities such as hypertension, diabetes, kidney, liver and heart diseases.

“These patients need more physiotherapists to attend to them as they are profoundly weak, with breathing difficulties and experiencing disorientation. All these factors would influence the patients’ capability and physiotherapists must assess their rehabilitation efforts with care,” said the Head of Physiotherapy Unit of Hospital Sultanah Amiah, Johor Bahru.

For categories 4 and 5 patients who are not on ventilator support, Nur Hidayah said a brief, yet concise explanation should be given and this poses a great challenge for physiotherapists who are sharing their knowledge on the breathing techniques for patients who have breathing difficulties and those with hypoxia (oxygen deficiency).

Meanwhile, President of the Malaysian Physiotherapy Association (MPA), Associate Prof Dr Mohd Haidzir Abd Manaf, 40, said it is crucial that physiotherapeutic treatment and rehabilitation be continued for Covid-19 patients after being discharged from the hospital. 

 “This includes special follow-ups for patients to return for their healthcare treatment as well as seeking guidance and advice from physiotherapists,” said Haidzir, who is also a senior lecturer from the Faculty of Health Sciences, Universiti Teknologi Mara, Shah Alam.

Long Covid

In conjunction with the annual World Physiotherapy celebration held on Sept 8, Mohd Haidzir said the World Physiotherapy Organisation has selected ‘Rehabilitation and Long Covid and the role of physiotherapists in the treatment and management of people affected by Long COVID’, as the theme of this year’s celebration.

“One out of 10 Covid-19 patients suffers from Long Covid (protracted Covid). Long Covid is when patients continue to have symptoms of Covid-19 for more than 12 weeks after the initial illness.

“Covid-19 patients usually have symptoms lasting up to four weeks after a person is infected, but ongoing symptoms will prolong up to 12 weeks and above,” he said.

He said Long Covid symptoms are characterised by post-exertional symptom exacerbation besides depression and concentration or memory issues.

 “As such, this year’s celebration provides an opportunity for physiotherapists worldwide to highlight the significance of their profession in enhancing the healthcare services for the general public who have been impacted by the Covid-19 pandemic,” he said.

The need for tele-physio at the national level

Mohd Haidzir said given that the Covid-19 pandemic reinforces the need for everyone to practise physical distancing, it is therefore crucial for hospitals in the country to implement tele-physiotherapy as a new normal in physiotherapeutic treatment.

“The process of rehabilitation is time-consuming, hence technology applications such as tele-physiotherapy is recommended not only for Covid-19 patients but also for non-Covid patients, senior citizens, children, disabled people and patients with chronic illnesses who are being treated by physiotherapists,” he said.

In this regard, the MPA is proposing a national plan to be implemented by the government, which covers guidelines for the online appointment system and video for a consistent rehabilitation for Covid-19 patients as well as non-Covid-19 patients.

 “This, not only helps to prevent patients from the potential risks of the virus, but also allows more patients to seek continuous physiotherapy rehabilitation treatment despite being discharged from the hospital,” he added. – Bernama  

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