On “Home and Community-Based Physical Therapist Management of Adults With Post–Intensive Care Syndrome.” Smith J, Lee AC, Zeleznik H, et al. Phys Ther. 2020;100:1062–1073

Outcome Assessment (Health Care), Ambulatory Care, Critical Illness, Outpatients

We were intrigued by “Home and Community-Based Physical Therapist Management of Adults with Post–Intensive Care Syndrome” by Smith and colleagues,¹ which serves as a guideline for navigating long term management of coronavirus. During a time of uncertainty, this article provided the Spaulding Rehabilitation Network pertinent information to better assess and treat our patients through the continuum of care.

As Smith et al describes, patients recovering from Acute Respiratory Distress Syndrome (ARDS) or critical illness often suffer from long-term effects, including prolonged weakness, cognitive impairments, and mental health impairments.¹ These deficits affect patients’ activities of daily living (ADLs), instrumental activities of daily living (IADLs), and quality of life. As a result, it is reasonable to expect that patients recovering from COVID-19 will have outpatient multidisciplinary rehabilitation needs that will require a continuum of care after discharge or diagnosis. As Smith et al suggests, outcome measures recommended for the critical illness population include: Medical Research Council Sum Score (MRC-SS), 6 Minute Walk Test (6MWT), the 4-Meter Walk Test, Berg Balance Scale, Functional Gait Assessment (FGA), Activities-Specific Balance Confidence Scale (ABC), Katz Index of Independence in ADL, the Lawton IADL questionnaire, and the Hospital Anxiety and Depression Scale.¹

We want to discuss the variability of the recommendations of Smith et al versus the APTA Academies and Sections Consensus Statement regarding COVID-19 Outcome Core Measures. The differences between assessment of endurance and balance and screening for mental health and cognitive impairments are most notable. The measures APTA suggested include Saint Louis University Mental Status examination (SLUMS) for cognition, PROMIS Global 10 (clinical practice or U.S. research) and EQ-5D-5L (international research) to address quality of life, MRC-SS for strength, Short Physical Performance Battery (SPPB) for function, and Two-Minute Step Test (TMST) for endurance.² We are reviewing the main differences, here, and providing our suggestions for applying these outcomes clinically.

APTA recommends the TMST, which differs from the Smith et al article suggestion of the 6MWT. We agree with a 6MWT versus a TMST for the following reasons: The 6MWT has been used and validated for the geriatric, neurologic, and orthopedic populations; the TMST is validated for the geriatric population and further validity, reliability, and responsiveness of the test is needed for additional populations.³ As we are aware, COVID-19 can affect patients with a multitude of impairments and commonly can affect the neurological system. COVID-19 is also presenting with varying age ranges, longevity, and acuteness. We propose that the 6MWT might be a broader test that captures more of the complications, manifestations, age ranges, and the varying stages of COVID-19 recovery.

For balance assessment, APTA suggests use of the SPPB for a test of function and balance. This test has a floor and ceiling effect; therefore, we believe that it is necessary to include the FGA test as stated in the Smith et al article should the ceiling effect be reached. The FGA provides insight on community level ambulation and dynamic balance, whereas the SPPB focuses on household level of balance. As we see patients with more chronic deficits and see effects in younger adults, it will be important to include higher-level balance testing to predict community outcomes.

Proper management of COVID-19 recovery will include a multidisciplinary team due to multisystem involvement. Smith et al suggest that it might be necessary for physical therapists to help educate and guide the primary care provider about the multisystem involvement in PICS and COVID-19 recovery.¹ This will include screening for speech-language pathology, occupational therapy, and mental/behavioral health intervention. APTA and Smith et al both offer different measures for these referrals; however, we propose a “subjective” screening on evaluation rather than specific testing due to the realistic time constraints of a physical therapist evaluation. This quick screen will provide the therapist with the guidance to determine if further follow-up is warranted. If a patient answers “yes,” this will prompt the clinician to either provide further objective testing within scope or generate referrals to other disciplines as indicated. The subjective screening questions that we propose include trouble with swallowing, return to drive/work, changes with cognition, difficulty with activities of daily living and instrumental activities of daily living, difficulty with fine motor tasks, and presence of incontinence. We also believe that a quick assessment for anxiety and depression using the PHQ-4 is warranted due to the high reported rates of PTSD, depression, and anxiety following COVID-19.⁴

To create an outcome measure battery for patients recovering from COVID-19 in our hospital network, we used a combination of the Smith et al recommendations and APTA’s Academies and Sections Consensus Statement regarding COVID-19 Core Outcome Measures. All the measures that we suggest are free, time efficient, have normative data, and demonstrate responsiveness over time. Additionally, they are clinically indicated and feasible for both inpatient rehabilitation and outpatient settings. The physical therapy outcome measures we propose include 6MWT for endurance; SBBP for function; MRC-SS for strength; FGA and ABC for dynamic balance and balance confidence, respectively; and the subjective screening noted above.

In addition to our evaluation battery, our hospital created an interdisciplinary clinical program with a team of therapists and physiatrists to address sequela. In Steere et al,⁵ it is suggested that physiatry-run outpatient COVID-19 recovery clinics can be organized to address rehabilitation related needs of patients who have suffered from COVID-19. They also suggest that there are ambulatory needs across cities that were highly impacted by COVID-19. We highly recommend this style of interdisciplinary clinical care, if possible.

In conclusion, Smith et al provides an excellent guideline for outcome measures and screening for patients recovering from COVID-19. Importantly, lack of optimal measures will limit our understanding of symptom longevity and sequela from the disease across care settings. Comprehensive though feasible outcome measurements are needed to serve as a foundation for future research of this novel diagnosis. We hope that this review will assist with physical therapists creating a plan to best assess during their evaluation.

Author Contributions

Writing: A.L. LaMarca, K.C. MacDonald

Disclosure

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.