Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series

Abstract Objective The aim of this case series was to describe the experience of Swiss physical therapists in the treatment of patients with COVID-19 during their acute care hospital stay and to discuss challenges and potential strategies in the clinical management of these patients. Methods We report 11 cases of patients with COVID-19 from 5 Swiss hospitals that illustrate the various indications for physical therapy, clinical challenges, potential treatment methods, and short-term response to treatment. Results Physical therapists actively treated patients with COVID-19 on wards and in the intensive care unit. Interventions ranged from patient education, to prone positioning, to early mobilization and respiratory therapy. Patients were often unstable with quick exacerbation of symptoms and a slow and fluctuant recovery. Additionally, many patients who were critically ill developed severe weakness, postextubation dysphagia, weaning failure, or presented with anxiety or delirium. In this setting, physical therapy was challenging and required specialized and individualized therapeutic strategies. Most patients adopted the proposed treatment strategies, and lung function and physical strength improved over time. Conclusion Physical therapists clearly have a role in the COVID-19 pandemic. Based on our experience in Switzerland, we recommend that physical therapists routinely screen and assess patients for respiratory symptoms and exercise tolerance on acute wards. Treatment of patients who are critically ill should start as soon as possible to limit further sequelae. More research is needed for awake prone positioning and early breathing exercises as well as post-COVID rehabilitation. Impact To date, there are few data on the physical therapist management of patients with COVID-19. This article is among the first to describe the role of physical therapists in the complex pandemic environment and to describe the potential treatment strategies for countering the various challenges in the treatment of these patients.


Settings
All five hospitals were highly involved in the primary care of COVID-19 patients.
These hospitals are representative of a large part of Switzerland and include the German and French speaking regions. Further information on hospitals and the physical therapist services is presented in the supplemental S1 Table. We did not allocate the names of the treating hospital to individual cases to ensure the anonymity of our patients.

Participant selection
This case report series aims to describe the wide spectrum of patient presentations as well as the large range of physical therapy interventions in order to illustrate the extensive role of physical therapists during the pandemic. Cases were therefore selected to represent this variety and have been titled accordingly.
In a first step, the first author (SE) contacted physical therapists from three other university hospitals and one large regional hospital to discuss their participation in this project. Subsequently, each hospital screened their current and past case load and had selected a few suitable candidates by the 27 th of April 2020. These potential cases were then discussed anonymously by phone or e-mail with the first author to discuss their eligibility. To limit repeated symptom presentation or therapy interventions, the ultimate decision to include a patient was made by the first author (SE).

Data collection
All cases were included retrospectively, whereby the majority were hospitalized patients at the time of recruitment. Routine hospital data and written informed consent were collected by the treating physical therapist. The data was collected over the four-week period from 20 th April 2020 to 18 th May 2020.

Implementation of prone positioning
ICU: prone positioning was medically led and initiated. PTs assisted in turning maneuvers and were responsible for correct positioning.
Prone positioning was medically led and initiated. PTs assisted in turning maneuvers and were responsible for correct positioning (daytime: specialized proning team including PT). OT responsible for awake proning.
ICU: prone positioning was medically led and initiated. PTs assisted in turning maneuvers and were responsible for correct positioning. Awake proning in non-intubated patients was led by PT following medical consultation. General wards: prone positioning was initiated and performed by PTs. If feasible, PT instructed nurses and patients in awake proning.
ICU: prone positioning was medically led and initiated. PTs assisted in turning maneuvers and supported correct positioning, when available, otherwise nurses performed the turning maneuvers and positioning General wards: prone positioning was initiated and performed by PTs. If feasible, PT instructed nurses and patients in awake proning.
ICU: prone positioning was medically led and initiated. PTs assisted in turning maneuvers and were responsible for correct positioning.
Intermediate Units: Selfproning strategy was led by PT following medical consultation and instructed to nurses and patients. Abbreviations: PT = physical therapist, OT = occupational therapist S1 Figure. Simulated 135° prone position.

Extended
Similar to a full prone position the 135° position aims to increase oxygenation by recruiting the dependent (dorsal) lung thus increasing the ventilation-perfusion ratio. It is especially useful if one lung is better than the other (good lung down principle) or for patients who do not tolerate the full prone position.
A: The 135° prone position was achieved for unconscious patients by sliding them to the edge of the bed, turning them to their side over their adducted arm and positioning them with several pillows as illustrated. The position was maintained for several hours similar to the full prone position. The maneuver requires about 5 helpers in mechanically ventilated, sedated patients.

B:
Awake patients were slowly guided through the same process step-by-step based on their abilities and with breaks as needed to avoid overexertion. Patients often spontaneously chose a position with both arms placed in front of them. The position was maintained as long as comfortable for the patient, usually between 30 to 90 minutes. The maneuver usually requires 1-2 helpers to secure lines and installations and to help with positioning.