What is RapidInfo4U?

Question

• What is the evidence to support high flow nasal oxygen in COVID-19 management?
• Does high flow nasal oxygen result in increased droplet dispersion and aerosol generation in COVID-19 patients?

Short Answer

High flow nasal oxygen for the management of COVID-19 is a controversial topic due to a lack of high-quality research into its efficacy and its potential as an aerosol-generating procedure. Systematic reviews commissioned by the World Health Organization found that high-flow nasal cannulas may reduce the need for invasive ventilation and the escalation of treatments over conventional oxygen therapy in COVID-19 patients. However, they caution that this potential advantage must be weighed against the currently unknown risk of droplet and aerosol transmission: there is currently no research evidence directly examining the consequent dispersion of COVID-19 virus for this procedure. A number of actions can reduce any potential risk: deliver HFNO in negative-pressure rooms and/or ensure proper ventilation; use an increased area of precaution; ensure staff have protective PPE; and place surgical masks on patients receiving the HFNO.

The content of this document is correct as of 04/12/20.

QUESTION

• Is there any evidence to suggest chest physiotherapy is an aerosol-generating procedure?
• Does the evidence compare different types of chest physiotherapy treatment techniques – and whether certain treatments may be more aerosol generating than others? (i.e. positive pressure devices, oscillating devices, cough assist, breathing techniques, patient coughing, suction etc).

SHORT ANSWER

There is insufficient evidence to state that chest physiotherapy is an aerosol-generating procedure. However, absence of evidence is not evidence of absence. International and national professional physiotherapy bodies have endorsed guidelines for physiotherapy management during COVID-19 which state that chest physiotherapy interventions are potentially aerosol-generating procedures and strongly recommend using airborne precautions when delivering these interventions. Furthermore, a recent systematic review classified chest physiotherapy interventions as potentially aerosol-generating and recommended, for the purposes of selecting personal protective equipment, that such procedures be treated as aerosol-generating.

The content of this document is correct as of 04/12/20.

Question

What is the latest evidence regarding conscious proning of COVID-19 patients?
At what level of oxygen is it best to commence proning?
When should you stop proning as the patient is improving?

Short Answer

The current evidence for conscious proning is of poor quality and fails to answer several key questions required to inform clinical practice, including the optimum conditions for commencing and ceasing proning. There are multiple RCTs underway that will address these gaps in knowledge over the coming months.

The content of this document is correct as of 27/11/2020.

Question

1.What is current guidance for cleaning a room after a hands-on physiotherapy session?

2.What are the current recommended products for effectively cleaning surfaces?

3.Do I have to wait a certain amount of time to clean my treatment room after a session?

Short answer

1.Clean with detergent and water followed by rinsing and drying. If a surface is suspected or known to have been contaminated by infectious material a disinfected should be used after cleaning.

2.A neutral detergent with water for cleaning and a chlorine-based product, such as sodium hypochlorite, for disinfecting.

3.HSPC cleaning protocols do not stipulate that a certain amount of time should be left between seeing a patient and cleaning. HSPC guidelines state that COVID-19 virus droplets produced by an infected patient will land on surfaces “within minutes” of production. They do not state how many minutes precisely. Research has found that large droplets fall within 1 second while smaller droplets can take up to 9 minutes to fall to the ground.

The content of this answer is correct as of 02/10/2020

Keeney, T. (2020). Physical Therapy in the COVID-19 Pandemic: Forging a Paradigm Shift for Rehabilitation in Acute Care. Physical therapy, 100(8), 1265-1267.

The COVID-19 pandemic is a crucible for health care systems across the country. Although rehabilitation utilization in hospitals varies enormously based on institution size, financial resources, and geographic location, it is clear that even in settings where acute care physical therapy is well staffed and well-funded, expansion of our roles is essential. Acute care physical therapists have long provided skilled evaluation and treatment in frenetic and fast-paced environments to patients struggling with serious illness. However, it is only by reacting to these new and difficult circumstances with growth and self-advocacy that we can forge a future characterized by intensive skilled rehabilitation services in the inpatient setting, simultaneously benefiting our health care systems and the patient populations we serve.

Click here for article

Stanhope, J., & Weinstein, P. (2020). Learning from COVID-19 to improve access to physiotherapy. Australian Journal of Primary Hehttps://www.publish.csiro.au/py/Fulltext/PY20141alth, 26(4), 271-272.

This letter states that funding for telehealth should continue post-COVID-19 and should include provision for tele-physiotherapy. The authors argue there are several instances where tele-physiotherapy may be an appropriate form of primary care, including the early management of acute pain, which may otherwise become chronic.

Click here for article

Polastri, M. (2020). Physiotherapy in hospitalised patients with COVID-19 disease: what we know so far. International Journal of Therapy and Rehabilitation, Vol. 27, No. 3.

This short editorial was published in April 2020.

Click here for article

Turolla, A., Rossettini, G., Viceconti, A., Palese, A., & Geri, T. (2020). Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer?. Physical therapy, 100(8), 1260-1264.

This article discuses the clinical evidence for telerehabilitation and examines the feasibility and acceptability of this approach. Both the opportunities and challenges of Telerehabilitation are addressed.

Click here for article

Polastri, M., Brini, S., Ghetti, A., & Lama, A. (2020). Recommendations from scientific/professional societies: an essential support for physiotherapy in patients with COVID-19.

The article emphasizes the need to develop a collective approach to how physiotherapy for COVID-19 patients should be implemented.

Topics discussed include:

-characteristics of treatment

-lessons learned from the COVID-19 outbreak

-recommendations provided by international scientific societies such as the World Confederation for Physical Therapy

-position papers released by the Italian Association of Respiratory Physiotherapists and other related organizations in Italy

Click here for article

Awan, M. M. A., Qureshi, S., & Khushnood, K. (2020). Cardiopulmonary Physical Therapist; A rescuer for the patients suffering from COVID-19. Pakistan Journal of Medical Sciences, 36(5).

The article discusses that according to World Health Organization (WHO), the ailments caused by viruses have always emerged in the past and exposed masses to life threatening medical conditions. It mentions the physiotherapists specialized in cardiopulmonary physical therapy are a life saver and rescuer for patients having COVID-19 and discusses the most common complications associated with COVID-19: acute respiratory distress syndrome (ARDS).

Click here for article

Özkeskin, M., Elibol, N., & Bakırhan, S. (2020). Risk of COVID-19 Disease in the Elderly Population and Physiotherapy. Physiotherapy.

In this letter to the editor, the authors conclude that elderly patients in ICU or hospital should have early physiotherapy treatment with medical treatment because early physiotherapy will be important for improvement of functional status and quality of life in the elderly in the early period after discharge.

Click here for letter

Thomas, P., Baldwin, C., Bissett, B., Boden, I., Gosselink, R., Granger, C. L., … & Ntoumenopoulos, G. (2020). Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. Journal of Physiotherapy.

This invited topical review outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19.

It includes:
• recommendations for physiotherapy workforce planning and preparation
• a screening tool for determining requirement for physiotherapy;
• recommendations for the selection of physiotherapy treatments and personal protective equipment

Click here for review

The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK’s 59,000 chartered physiotherapists, physiotherapy students and support workers.

The CSP have a range of resources and guides available here for the rapid implementation of remote physiotherapy delivery

This guide was developed by the Irish Society of Chartered Physiotherapists’ (ISCP) Clinical Interest Group in Neurology and Gerontology. It is a guide for treating older people post COVID-19 in hospital, post-acute care and the community.

A Coping with Breathlessness poster courtesy of the Dept of Physiotherapy, Pulmonary Rehabilitation, University Hospital Limerick.

The purpose of this document is to update the 1999 ATS
Consensus Statement on dyspnea.

A Progressive Muscle Relaxation script for Pulmonary Rehabilitation courtesy of the Dept of Physiotherapy, University Hospital Limerick.

Developed by the Leeds Teaching Hospitals NHS Trust by a group of Allied Health Professional (AHPs) who came together to develop some original work done by the Liverpool Heart and Chest Hospital into a COVID-19 patient rehabilitation booklet.

This booklet provides patients and their families information on all aspects of the COVID-19 rehabilitation process, with key areas being: breathing, exercise, diet, swallowing and speech, fatigue and post-traumatic stress.

Click here for booklet.

Parshall, M. B., Schwartzstein, R. M., Adams, L., Banzett, R. B., Manning, H. L., Bourbeau, J., … & Mahler, D. A. (2012). An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine, 185(4), 435-452.

This is an American Thoracic Society Statement from 2012 providing an update on the Mechanisms, Assessment, and Management of Dyspnea

Click here for statement

Vitacca, M., Carone, M., Clini, E. M., Paneroni, M., Lazzeri, M., Lanza, A., … & Banfi, P. (2020). Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis: the Italian position paper. Respiration, 1-7.

Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis from the Italian Thoracic Society (ITS – AIPO), Association for the Rehabilitation of Respiratory Failure (ARIR) and the Italian Respiratory Society (SIP/IRS).

This joint statement is a Consensus Statement on Respiratory Rehabilitation in patients with COVID-19. It is based on the general experience so far in dealing with the disease and on the existing knowledge of the ITS – AIPO, ARIR and the SIP/IRS.

This joint statement represents an expert opinion of clinicians engaged in the field of RR, called – together with other specialities – to face with this emergency. It summarises the recommendations they consider most appropriate and urgent.

World Health Organization, 2020. Support for Rehabilitation Self-Management after COVID-19-Related Illness (No. WHO/EURO: 2020-855-40590-54571). World Health Organization. Regional Office for Europe.

This leaflet provides basic exercises and advice for adults who have been severely unwell and admitted to the hospital with COVID-19. It provides information on the following areas:

• Managing breathlessness
• Exercising after leaving hospital
• Managing problems with your voice
• Managing eating, drinking, and swallowing
• Managing problems with attention, memory, and thinking clearly
• Managing activities of daily living
• Managing stress, anxiety, or depression

Click here for document

Laviolette, L., & Laveneziana, P. (2014). Dyspnoea: a multidimensional and multidisciplinary approach. European Respiratory Journal, 43(6), 1750-1762.

Dyspnoea is a debilitating symptom that affects quality of life, exercise tolerance and mortality in various disease conditions/states. In patients with chronic obstructive pulmonary disease (COPD), it has been shown to be a better predictor of mortality than forced expiratory volume in 1 s. In patients with heart disease it is a better predictor of mortality than angina. Dyspnoea is also associated with decreased functional status and worse psychological health in older individuals living at home. It also contributes to the low adherence to exercise training programmes in sedentary adults and in COPD patients.

The mechanisms of dyspnoea are still unclear. Recent studies have emphasised the multidimensional nature of dyspnoea in the sensory–perceptual (intensity and quality), affective distress and impact domains. The perception of dyspnoea involves a complex chain of events that depend on varying cortical integration of several afferent/efferent signals and coloured by affective processing.

This review, which stems from the European Respiratory Society research symposium held in Paris, France in November 2012, aims to provide state-of-the-art advances on the multidimensional and multidisciplinary aspects of dyspnoea, by addressing three different themes:

1. the neurophysiology of dyspnoea
2. exercise and dyspnoea
3. the clinical impact and management of dyspnoea

Click here for review

Question

• What is the evidence to support high flow nasal oxygen in COVID-19 management?
• Does high flow nasal oxygen result in increased droplet dispersion and aerosol generation in COVID-19 patients?

Short Answer

High flow nasal oxygen for the management of COVID-19 is a controversial topic due to a lack of high-quality research into its efficacy and its potential as an aerosol-generating procedure. Systematic reviews commissioned by the World Health Organization found that high-flow nasal cannulas may reduce the need for invasive ventilation and the escalation of treatments over conventional oxygen therapy in COVID-19 patients. However, they caution that this potential advantage must be weighed against the currently unknown risk of droplet and aerosol transmission: there is currently no research evidence directly examining the consequent dispersion of COVID-19 virus for this procedure. A number of actions can reduce any potential risk: deliver HFNO in negative-pressure rooms and/or ensure proper ventilation; use an increased area of precaution; ensure staff have protective PPE; and place surgical masks on patients receiving the HFNO.

The content of this document is correct as of 04/12/20.

QUESTION

• Is there any evidence to suggest chest physiotherapy is an aerosol-generating procedure?
• Does the evidence compare different types of chest physiotherapy treatment techniques – and whether certain treatments may be more aerosol generating than others? (i.e. positive pressure devices, oscillating devices, cough assist, breathing techniques, patient coughing, suction etc).

SHORT ANSWER

There is insufficient evidence to state that chest physiotherapy is an aerosol-generating procedure. However, absence of evidence is not evidence of absence. International and national professional physiotherapy bodies have endorsed guidelines for physiotherapy management during COVID-19 which state that chest physiotherapy interventions are potentially aerosol-generating procedures and strongly recommend using airborne precautions when delivering these interventions. Furthermore, a recent systematic review classified chest physiotherapy interventions as potentially aerosol-generating and recommended, for the purposes of selecting personal protective equipment, that such procedures be treated as aerosol-generating.

The content of this document is correct as of 04/12/20.

Question

What is the latest evidence regarding conscious proning of COVID-19 patients?
At what level of oxygen is it best to commence proning?
When should you stop proning as the patient is improving?

Short Answer

The current evidence for conscious proning is of poor quality and fails to answer several key questions required to inform clinical practice, including the optimum conditions for commencing and ceasing proning. There are multiple RCTs underway that will address these gaps in knowledge over the coming months.

The content of this document is correct as of 27/11/2020.

Question

1.What is current guidance for cleaning a room after a hands-on physiotherapy session?

2.What are the current recommended products for effectively cleaning surfaces?

3.Do I have to wait a certain amount of time to clean my treatment room after a session?

Short answer

1.Clean with detergent and water followed by rinsing and drying. If a surface is suspected or known to have been contaminated by infectious material a disinfected should be used after cleaning.

2.A neutral detergent with water for cleaning and a chlorine-based product, such as sodium hypochlorite, for disinfecting.

3.HSPC cleaning protocols do not stipulate that a certain amount of time should be left between seeing a patient and cleaning. HSPC guidelines state that COVID-19 virus droplets produced by an infected patient will land on surfaces “within minutes” of production. They do not state how many minutes precisely. Research has found that large droplets fall within 1 second while smaller droplets can take up to 9 minutes to fall to the ground.

The content of this answer is correct as of 02/10/2020

Keeney, T. (2020). Physical Therapy in the COVID-19 Pandemic: Forging a Paradigm Shift for Rehabilitation in Acute Care. Physical therapy, 100(8), 1265-1267.

The COVID-19 pandemic is a crucible for health care systems across the country. Although rehabilitation utilization in hospitals varies enormously based on institution size, financial resources, and geographic location, it is clear that even in settings where acute care physical therapy is well staffed and well-funded, expansion of our roles is essential. Acute care physical therapists have long provided skilled evaluation and treatment in frenetic and fast-paced environments to patients struggling with serious illness. However, it is only by reacting to these new and difficult circumstances with growth and self-advocacy that we can forge a future characterized by intensive skilled rehabilitation services in the inpatient setting, simultaneously benefiting our health care systems and the patient populations we serve.

Click here for article

Stanhope, J., & Weinstein, P. (2020). Learning from COVID-19 to improve access to physiotherapy. Australian Journal of Primary Hehttps://www.publish.csiro.au/py/Fulltext/PY20141alth, 26(4), 271-272.

This letter states that funding for telehealth should continue post-COVID-19 and should include provision for tele-physiotherapy. The authors argue there are several instances where tele-physiotherapy may be an appropriate form of primary care, including the early management of acute pain, which may otherwise become chronic.

Click here for article

Polastri, M. (2020). Physiotherapy in hospitalised patients with COVID-19 disease: what we know so far. International Journal of Therapy and Rehabilitation, Vol. 27, No. 3.

This short editorial was published in April 2020.

Click here for article

Turolla, A., Rossettini, G., Viceconti, A., Palese, A., & Geri, T. (2020). Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer?. Physical therapy, 100(8), 1260-1264.

This article discuses the clinical evidence for telerehabilitation and examines the feasibility and acceptability of this approach. Both the opportunities and challenges of Telerehabilitation are addressed.

Click here for article

Polastri, M., Brini, S., Ghetti, A., & Lama, A. (2020). Recommendations from scientific/professional societies: an essential support for physiotherapy in patients with COVID-19.

The article emphasizes the need to develop a collective approach to how physiotherapy for COVID-19 patients should be implemented.

Topics discussed include:

-characteristics of treatment

-lessons learned from the COVID-19 outbreak

-recommendations provided by international scientific societies such as the World Confederation for Physical Therapy

-position papers released by the Italian Association of Respiratory Physiotherapists and other related organizations in Italy

Click here for article

Awan, M. M. A., Qureshi, S., & Khushnood, K. (2020). Cardiopulmonary Physical Therapist; A rescuer for the patients suffering from COVID-19. Pakistan Journal of Medical Sciences, 36(5).

The article discusses that according to World Health Organization (WHO), the ailments caused by viruses have always emerged in the past and exposed masses to life threatening medical conditions. It mentions the physiotherapists specialized in cardiopulmonary physical therapy are a life saver and rescuer for patients having COVID-19 and discusses the most common complications associated with COVID-19: acute respiratory distress syndrome (ARDS).

Click here for article

Özkeskin, M., Elibol, N., & Bakırhan, S. (2020). Risk of COVID-19 Disease in the Elderly Population and Physiotherapy. Physiotherapy.

In this letter to the editor, the authors conclude that elderly patients in ICU or hospital should have early physiotherapy treatment with medical treatment because early physiotherapy will be important for improvement of functional status and quality of life in the elderly in the early period after discharge.

Click here for letter

Thomas, P., Baldwin, C., Bissett, B., Boden, I., Gosselink, R., Granger, C. L., … & Ntoumenopoulos, G. (2020). Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. Journal of Physiotherapy.

This invited topical review outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19.

It includes:
• recommendations for physiotherapy workforce planning and preparation
• a screening tool for determining requirement for physiotherapy;
• recommendations for the selection of physiotherapy treatments and personal protective equipment

Click here for review

The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK’s 59,000 chartered physiotherapists, physiotherapy students and support workers.

The CSP have a range of resources and guides available here for the rapid implementation of remote physiotherapy delivery

This guide was developed by the Irish Society of Chartered Physiotherapists’ (ISCP) Clinical Interest Group in Neurology and Gerontology. It is a guide for treating older people post COVID-19 in hospital, post-acute care and the community.

A Coping with Breathlessness poster courtesy of the Dept of Physiotherapy, Pulmonary Rehabilitation, University Hospital Limerick.

The purpose of this document is to update the 1999 ATS
Consensus Statement on dyspnea.

A Progressive Muscle Relaxation script for Pulmonary Rehabilitation courtesy of the Dept of Physiotherapy, University Hospital Limerick.

Developed by the Leeds Teaching Hospitals NHS Trust by a group of Allied Health Professional (AHPs) who came together to develop some original work done by the Liverpool Heart and Chest Hospital into a COVID-19 patient rehabilitation booklet.

This booklet provides patients and their families information on all aspects of the COVID-19 rehabilitation process, with key areas being: breathing, exercise, diet, swallowing and speech, fatigue and post-traumatic stress.

Click here for booklet.

Parshall, M. B., Schwartzstein, R. M., Adams, L., Banzett, R. B., Manning, H. L., Bourbeau, J., … & Mahler, D. A. (2012). An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine, 185(4), 435-452.

This is an American Thoracic Society Statement from 2012 providing an update on the Mechanisms, Assessment, and Management of Dyspnea

Click here for statement

Vitacca, M., Carone, M., Clini, E. M., Paneroni, M., Lazzeri, M., Lanza, A., … & Banfi, P. (2020). Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis: the Italian position paper. Respiration, 1-7.

Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis from the Italian Thoracic Society (ITS – AIPO), Association for the Rehabilitation of Respiratory Failure (ARIR) and the Italian Respiratory Society (SIP/IRS).

This joint statement is a Consensus Statement on Respiratory Rehabilitation in patients with COVID-19. It is based on the general experience so far in dealing with the disease and on the existing knowledge of the ITS – AIPO, ARIR and the SIP/IRS.

This joint statement represents an expert opinion of clinicians engaged in the field of RR, called – together with other specialities – to face with this emergency. It summarises the recommendations they consider most appropriate and urgent.

World Health Organization, 2020. Support for Rehabilitation Self-Management after COVID-19-Related Illness (No. WHO/EURO: 2020-855-40590-54571). World Health Organization. Regional Office for Europe.

This leaflet provides basic exercises and advice for adults who have been severely unwell and admitted to the hospital with COVID-19. It provides information on the following areas:

• Managing breathlessness
• Exercising after leaving hospital
• Managing problems with your voice
• Managing eating, drinking, and swallowing
• Managing problems with attention, memory, and thinking clearly
• Managing activities of daily living
• Managing stress, anxiety, or depression

Click here for document

Laviolette, L., & Laveneziana, P. (2014). Dyspnoea: a multidimensional and multidisciplinary approach. European Respiratory Journal, 43(6), 1750-1762.

Dyspnoea is a debilitating symptom that affects quality of life, exercise tolerance and mortality in various disease conditions/states. In patients with chronic obstructive pulmonary disease (COPD), it has been shown to be a better predictor of mortality than forced expiratory volume in 1 s. In patients with heart disease it is a better predictor of mortality than angina. Dyspnoea is also associated with decreased functional status and worse psychological health in older individuals living at home. It also contributes to the low adherence to exercise training programmes in sedentary adults and in COPD patients.

The mechanisms of dyspnoea are still unclear. Recent studies have emphasised the multidimensional nature of dyspnoea in the sensory–perceptual (intensity and quality), affective distress and impact domains. The perception of dyspnoea involves a complex chain of events that depend on varying cortical integration of several afferent/efferent signals and coloured by affective processing.

This review, which stems from the European Respiratory Society research symposium held in Paris, France in November 2012, aims to provide state-of-the-art advances on the multidimensional and multidisciplinary aspects of dyspnoea, by addressing three different themes:

1. the neurophysiology of dyspnoea
2. exercise and dyspnoea
3. the clinical impact and management of dyspnoea

Click here for review

Question

• What is the evidence to support high flow nasal oxygen in COVID-19 management?
• Does high flow nasal oxygen result in increased droplet dispersion and aerosol generation in COVID-19 patients?

Short Answer

High flow nasal oxygen for the management of COVID-19 is a controversial topic due to a lack of high-quality research into its efficacy and its potential as an aerosol-generating procedure. Systematic reviews commissioned by the World Health Organization found that high-flow nasal cannulas may reduce the need for invasive ventilation and the escalation of treatments over conventional oxygen therapy in COVID-19 patients. However, they caution that this potential advantage must be weighed against the currently unknown risk of droplet and aerosol transmission: there is currently no research evidence directly examining the consequent dispersion of COVID-19 virus for this procedure. A number of actions can reduce any potential risk: deliver HFNO in negative-pressure rooms and/or ensure proper ventilation; use an increased area of precaution; ensure staff have protective PPE; and place surgical masks on patients receiving the HFNO.

The content of this document is correct as of 04/12/20.

QUESTION

• Is there any evidence to suggest chest physiotherapy is an aerosol-generating procedure?
• Does the evidence compare different types of chest physiotherapy treatment techniques – and whether certain treatments may be more aerosol generating than others? (i.e. positive pressure devices, oscillating devices, cough assist, breathing techniques, patient coughing, suction etc).

SHORT ANSWER

There is insufficient evidence to state that chest physiotherapy is an aerosol-generating procedure. However, absence of evidence is not evidence of absence. International and national professional physiotherapy bodies have endorsed guidelines for physiotherapy management during COVID-19 which state that chest physiotherapy interventions are potentially aerosol-generating procedures and strongly recommend using airborne precautions when delivering these interventions. Furthermore, a recent systematic review classified chest physiotherapy interventions as potentially aerosol-generating and recommended, for the purposes of selecting personal protective equipment, that such procedures be treated as aerosol-generating.

The content of this document is correct as of 04/12/20.

Question

What is the latest evidence regarding conscious proning of COVID-19 patients?
At what level of oxygen is it best to commence proning?
When should you stop proning as the patient is improving?

Short Answer

The current evidence for conscious proning is of poor quality and fails to answer several key questions required to inform clinical practice, including the optimum conditions for commencing and ceasing proning. There are multiple RCTs underway that will address these gaps in knowledge over the coming months.

The content of this document is correct as of 27/11/2020.

Question

1.What is current guidance for cleaning a room after a hands-on physiotherapy session?

2.What are the current recommended products for effectively cleaning surfaces?

3.Do I have to wait a certain amount of time to clean my treatment room after a session?

Short answer

1.Clean with detergent and water followed by rinsing and drying. If a surface is suspected or known to have been contaminated by infectious material a disinfected should be used after cleaning.

2.A neutral detergent with water for cleaning and a chlorine-based product, such as sodium hypochlorite, for disinfecting.

3.HSPC cleaning protocols do not stipulate that a certain amount of time should be left between seeing a patient and cleaning. HSPC guidelines state that COVID-19 virus droplets produced by an infected patient will land on surfaces “within minutes” of production. They do not state how many minutes precisely. Research has found that large droplets fall within 1 second while smaller droplets can take up to 9 minutes to fall to the ground.

The content of this answer is correct as of 02/10/2020

Keeney, T. (2020). Physical Therapy in the COVID-19 Pandemic: Forging a Paradigm Shift for Rehabilitation in Acute Care. Physical therapy, 100(8), 1265-1267.

The COVID-19 pandemic is a crucible for health care systems across the country. Although rehabilitation utilization in hospitals varies enormously based on institution size, financial resources, and geographic location, it is clear that even in settings where acute care physical therapy is well staffed and well-funded, expansion of our roles is essential. Acute care physical therapists have long provided skilled evaluation and treatment in frenetic and fast-paced environments to patients struggling with serious illness. However, it is only by reacting to these new and difficult circumstances with growth and self-advocacy that we can forge a future characterized by intensive skilled rehabilitation services in the inpatient setting, simultaneously benefiting our health care systems and the patient populations we serve.

Click here for article

Stanhope, J., & Weinstein, P. (2020). Learning from COVID-19 to improve access to physiotherapy. Australian Journal of Primary Hehttps://www.publish.csiro.au/py/Fulltext/PY20141alth, 26(4), 271-272.

This letter states that funding for telehealth should continue post-COVID-19 and should include provision for tele-physiotherapy. The authors argue there are several instances where tele-physiotherapy may be an appropriate form of primary care, including the early management of acute pain, which may otherwise become chronic.

Click here for article

Polastri, M. (2020). Physiotherapy in hospitalised patients with COVID-19 disease: what we know so far. International Journal of Therapy and Rehabilitation, Vol. 27, No. 3.

This short editorial was published in April 2020.

Click here for article

Turolla, A., Rossettini, G., Viceconti, A., Palese, A., & Geri, T. (2020). Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer?. Physical therapy, 100(8), 1260-1264.

This article discuses the clinical evidence for telerehabilitation and examines the feasibility and acceptability of this approach. Both the opportunities and challenges of Telerehabilitation are addressed.

Click here for article

Polastri, M., Brini, S., Ghetti, A., & Lama, A. (2020). Recommendations from scientific/professional societies: an essential support for physiotherapy in patients with COVID-19.

The article emphasizes the need to develop a collective approach to how physiotherapy for COVID-19 patients should be implemented.

Topics discussed include:

-characteristics of treatment

-lessons learned from the COVID-19 outbreak

-recommendations provided by international scientific societies such as the World Confederation for Physical Therapy

-position papers released by the Italian Association of Respiratory Physiotherapists and other related organizations in Italy

Click here for article

Awan, M. M. A., Qureshi, S., & Khushnood, K. (2020). Cardiopulmonary Physical Therapist; A rescuer for the patients suffering from COVID-19. Pakistan Journal of Medical Sciences, 36(5).

The article discusses that according to World Health Organization (WHO), the ailments caused by viruses have always emerged in the past and exposed masses to life threatening medical conditions. It mentions the physiotherapists specialized in cardiopulmonary physical therapy are a life saver and rescuer for patients having COVID-19 and discusses the most common complications associated with COVID-19: acute respiratory distress syndrome (ARDS).

Click here for article

Özkeskin, M., Elibol, N., & Bakırhan, S. (2020). Risk of COVID-19 Disease in the Elderly Population and Physiotherapy. Physiotherapy.

In this letter to the editor, the authors conclude that elderly patients in ICU or hospital should have early physiotherapy treatment with medical treatment because early physiotherapy will be important for improvement of functional status and quality of life in the elderly in the early period after discharge.

Click here for letter

Thomas, P., Baldwin, C., Bissett, B., Boden, I., Gosselink, R., Granger, C. L., … & Ntoumenopoulos, G. (2020). Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. Journal of Physiotherapy.

This invited topical review outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19.

It includes:
• recommendations for physiotherapy workforce planning and preparation
• a screening tool for determining requirement for physiotherapy;
• recommendations for the selection of physiotherapy treatments and personal protective equipment

Click here for review

The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK’s 59,000 chartered physiotherapists, physiotherapy students and support workers.

The CSP have a range of resources and guides available here for the rapid implementation of remote physiotherapy delivery

This guide was developed by the Irish Society of Chartered Physiotherapists’ (ISCP) Clinical Interest Group in Neurology and Gerontology. It is a guide for treating older people post COVID-19 in hospital, post-acute care and the community.

A Coping with Breathlessness poster courtesy of the Dept of Physiotherapy, Pulmonary Rehabilitation, University Hospital Limerick.

The purpose of this document is to update the 1999 ATS
Consensus Statement on dyspnea.

A Progressive Muscle Relaxation script for Pulmonary Rehabilitation courtesy of the Dept of Physiotherapy, University Hospital Limerick.

Developed by the Leeds Teaching Hospitals NHS Trust by a group of Allied Health Professional (AHPs) who came together to develop some original work done by the Liverpool Heart and Chest Hospital into a COVID-19 patient rehabilitation booklet.

This booklet provides patients and their families information on all aspects of the COVID-19 rehabilitation process, with key areas being: breathing, exercise, diet, swallowing and speech, fatigue and post-traumatic stress.

Click here for booklet.

Parshall, M. B., Schwartzstein, R. M., Adams, L., Banzett, R. B., Manning, H. L., Bourbeau, J., … & Mahler, D. A. (2012). An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine, 185(4), 435-452.

This is an American Thoracic Society Statement from 2012 providing an update on the Mechanisms, Assessment, and Management of Dyspnea

Click here for statement

Vitacca, M., Carone, M., Clini, E. M., Paneroni, M., Lazzeri, M., Lanza, A., … & Banfi, P. (2020). Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis: the Italian position paper. Respiration, 1-7.

Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis from the Italian Thoracic Society (ITS – AIPO), Association for the Rehabilitation of Respiratory Failure (ARIR) and the Italian Respiratory Society (SIP/IRS).

This joint statement is a Consensus Statement on Respiratory Rehabilitation in patients with COVID-19. It is based on the general experience so far in dealing with the disease and on the existing knowledge of the ITS – AIPO, ARIR and the SIP/IRS.

This joint statement represents an expert opinion of clinicians engaged in the field of RR, called – together with other specialities – to face with this emergency. It summarises the recommendations they consider most appropriate and urgent.

World Health Organization, 2020. Support for Rehabilitation Self-Management after COVID-19-Related Illness (No. WHO/EURO: 2020-855-40590-54571). World Health Organization. Regional Office for Europe.

This leaflet provides basic exercises and advice for adults who have been severely unwell and admitted to the hospital with COVID-19. It provides information on the following areas:

• Managing breathlessness
• Exercising after leaving hospital
• Managing problems with your voice
• Managing eating, drinking, and swallowing
• Managing problems with attention, memory, and thinking clearly
• Managing activities of daily living
• Managing stress, anxiety, or depression

Click here for document

Laviolette, L., & Laveneziana, P. (2014). Dyspnoea: a multidimensional and multidisciplinary approach. European Respiratory Journal, 43(6), 1750-1762.

Dyspnoea is a debilitating symptom that affects quality of life, exercise tolerance and mortality in various disease conditions/states. In patients with chronic obstructive pulmonary disease (COPD), it has been shown to be a better predictor of mortality than forced expiratory volume in 1 s. In patients with heart disease it is a better predictor of mortality than angina. Dyspnoea is also associated with decreased functional status and worse psychological health in older individuals living at home. It also contributes to the low adherence to exercise training programmes in sedentary adults and in COPD patients.

The mechanisms of dyspnoea are still unclear. Recent studies have emphasised the multidimensional nature of dyspnoea in the sensory–perceptual (intensity and quality), affective distress and impact domains. The perception of dyspnoea involves a complex chain of events that depend on varying cortical integration of several afferent/efferent signals and coloured by affective processing.

This review, which stems from the European Respiratory Society research symposium held in Paris, France in November 2012, aims to provide state-of-the-art advances on the multidimensional and multidisciplinary aspects of dyspnoea, by addressing three different themes:

1. the neurophysiology of dyspnoea
2. exercise and dyspnoea
3. the clinical impact and management of dyspnoea

Click here for review

Question

• What is the evidence to support high flow nasal oxygen in COVID-19 management?
• Does high flow nasal oxygen result in increased droplet dispersion and aerosol generation in COVID-19 patients?

Short Answer

High flow nasal oxygen for the management of COVID-19 is a controversial topic due to a lack of high-quality research into its efficacy and its potential as an aerosol-generating procedure. Systematic reviews commissioned by the World Health Organization found that high-flow nasal cannulas may reduce the need for invasive ventilation and the escalation of treatments over conventional oxygen therapy in COVID-19 patients. However, they caution that this potential advantage must be weighed against the currently unknown risk of droplet and aerosol transmission: there is currently no research evidence directly examining the consequent dispersion of COVID-19 virus for this procedure. A number of actions can reduce any potential risk: deliver HFNO in negative-pressure rooms and/or ensure proper ventilation; use an increased area of precaution; ensure staff have protective PPE; and place surgical masks on patients receiving the HFNO.

The content of this document is correct as of 04/12/20.

QUESTION

• Is there any evidence to suggest chest physiotherapy is an aerosol-generating procedure?
• Does the evidence compare different types of chest physiotherapy treatment techniques – and whether certain treatments may be more aerosol generating than others? (i.e. positive pressure devices, oscillating devices, cough assist, breathing techniques, patient coughing, suction etc).

SHORT ANSWER

There is insufficient evidence to state that chest physiotherapy is an aerosol-generating procedure. However, absence of evidence is not evidence of absence. International and national professional physiotherapy bodies have endorsed guidelines for physiotherapy management during COVID-19 which state that chest physiotherapy interventions are potentially aerosol-generating procedures and strongly recommend using airborne precautions when delivering these interventions. Furthermore, a recent systematic review classified chest physiotherapy interventions as potentially aerosol-generating and recommended, for the purposes of selecting personal protective equipment, that such procedures be treated as aerosol-generating.

The content of this document is correct as of 04/12/20.

Question

What is the latest evidence regarding conscious proning of COVID-19 patients?
At what level of oxygen is it best to commence proning?
When should you stop proning as the patient is improving?

Short Answer

The current evidence for conscious proning is of poor quality and fails to answer several key questions required to inform clinical practice, including the optimum conditions for commencing and ceasing proning. There are multiple RCTs underway that will address these gaps in knowledge over the coming months.

The content of this document is correct as of 27/11/2020.

Question

1.What is current guidance for cleaning a room after a hands-on physiotherapy session?

2.What are the current recommended products for effectively cleaning surfaces?

3.Do I have to wait a certain amount of time to clean my treatment room after a session?

Short answer

1.Clean with detergent and water followed by rinsing and drying. If a surface is suspected or known to have been contaminated by infectious material a disinfected should be used after cleaning.

2.A neutral detergent with water for cleaning and a chlorine-based product, such as sodium hypochlorite, for disinfecting.

3.HSPC cleaning protocols do not stipulate that a certain amount of time should be left between seeing a patient and cleaning. HSPC guidelines state that COVID-19 virus droplets produced by an infected patient will land on surfaces “within minutes” of production. They do not state how many minutes precisely. Research has found that large droplets fall within 1 second while smaller droplets can take up to 9 minutes to fall to the ground.

The content of this answer is correct as of 02/10/2020

Keeney, T. (2020). Physical Therapy in the COVID-19 Pandemic: Forging a Paradigm Shift for Rehabilitation in Acute Care. Physical therapy, 100(8), 1265-1267.

The COVID-19 pandemic is a crucible for health care systems across the country. Although rehabilitation utilization in hospitals varies enormously based on institution size, financial resources, and geographic location, it is clear that even in settings where acute care physical therapy is well staffed and well-funded, expansion of our roles is essential. Acute care physical therapists have long provided skilled evaluation and treatment in frenetic and fast-paced environments to patients struggling with serious illness. However, it is only by reacting to these new and difficult circumstances with growth and self-advocacy that we can forge a future characterized by intensive skilled rehabilitation services in the inpatient setting, simultaneously benefiting our health care systems and the patient populations we serve.

Click here for article

Stanhope, J., & Weinstein, P. (2020). Learning from COVID-19 to improve access to physiotherapy. Australian Journal of Primary Hehttps://www.publish.csiro.au/py/Fulltext/PY20141alth, 26(4), 271-272.

This letter states that funding for telehealth should continue post-COVID-19 and should include provision for tele-physiotherapy. The authors argue there are several instances where tele-physiotherapy may be an appropriate form of primary care, including the early management of acute pain, which may otherwise become chronic.

Click here for article

Polastri, M. (2020). Physiotherapy in hospitalised patients with COVID-19 disease: what we know so far. International Journal of Therapy and Rehabilitation, Vol. 27, No. 3.

This short editorial was published in April 2020.

Click here for article

Turolla, A., Rossettini, G., Viceconti, A., Palese, A., & Geri, T. (2020). Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer?. Physical therapy, 100(8), 1260-1264.

This article discuses the clinical evidence for telerehabilitation and examines the feasibility and acceptability of this approach. Both the opportunities and challenges of Telerehabilitation are addressed.

Click here for article

Polastri, M., Brini, S., Ghetti, A., & Lama, A. (2020). Recommendations from scientific/professional societies: an essential support for physiotherapy in patients with COVID-19.

The article emphasizes the need to develop a collective approach to how physiotherapy for COVID-19 patients should be implemented.

Topics discussed include:

-characteristics of treatment

-lessons learned from the COVID-19 outbreak

-recommendations provided by international scientific societies such as the World Confederation for Physical Therapy

-position papers released by the Italian Association of Respiratory Physiotherapists and other related organizations in Italy

Click here for article

Awan, M. M. A., Qureshi, S., & Khushnood, K. (2020). Cardiopulmonary Physical Therapist; A rescuer for the patients suffering from COVID-19. Pakistan Journal of Medical Sciences, 36(5).

The article discusses that according to World Health Organization (WHO), the ailments caused by viruses have always emerged in the past and exposed masses to life threatening medical conditions. It mentions the physiotherapists specialized in cardiopulmonary physical therapy are a life saver and rescuer for patients having COVID-19 and discusses the most common complications associated with COVID-19: acute respiratory distress syndrome (ARDS).

Click here for article

Özkeskin, M., Elibol, N., & Bakırhan, S. (2020). Risk of COVID-19 Disease in the Elderly Population and Physiotherapy. Physiotherapy.

In this letter to the editor, the authors conclude that elderly patients in ICU or hospital should have early physiotherapy treatment with medical treatment because early physiotherapy will be important for improvement of functional status and quality of life in the elderly in the early period after discharge.

Click here for letter

Thomas, P., Baldwin, C., Bissett, B., Boden, I., Gosselink, R., Granger, C. L., … & Ntoumenopoulos, G. (2020). Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. Journal of Physiotherapy.

This invited topical review outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19.

It includes:
• recommendations for physiotherapy workforce planning and preparation
• a screening tool for determining requirement for physiotherapy;
• recommendations for the selection of physiotherapy treatments and personal protective equipment

Click here for review

The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK’s 59,000 chartered physiotherapists, physiotherapy students and support workers.

The CSP have a range of resources and guides available here for the rapid implementation of remote physiotherapy delivery

This guide was developed by the Irish Society of Chartered Physiotherapists’ (ISCP) Clinical Interest Group in Neurology and Gerontology. It is a guide for treating older people post COVID-19 in hospital, post-acute care and the community.

A Coping with Breathlessness poster courtesy of the Dept of Physiotherapy, Pulmonary Rehabilitation, University Hospital Limerick.

The purpose of this document is to update the 1999 ATS
Consensus Statement on dyspnea.

A Progressive Muscle Relaxation script for Pulmonary Rehabilitation courtesy of the Dept of Physiotherapy, University Hospital Limerick.

Developed by the Leeds Teaching Hospitals NHS Trust by a group of Allied Health Professional (AHPs) who came together to develop some original work done by the Liverpool Heart and Chest Hospital into a COVID-19 patient rehabilitation booklet.

This booklet provides patients and their families information on all aspects of the COVID-19 rehabilitation process, with key areas being: breathing, exercise, diet, swallowing and speech, fatigue and post-traumatic stress.

Click here for booklet.

Parshall, M. B., Schwartzstein, R. M., Adams, L., Banzett, R. B., Manning, H. L., Bourbeau, J., … & Mahler, D. A. (2012). An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine, 185(4), 435-452.

This is an American Thoracic Society Statement from 2012 providing an update on the Mechanisms, Assessment, and Management of Dyspnea

Click here for statement

Vitacca, M., Carone, M., Clini, E. M., Paneroni, M., Lazzeri, M., Lanza, A., … & Banfi, P. (2020). Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis: the Italian position paper. Respiration, 1-7.

Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis from the Italian Thoracic Society (ITS – AIPO), Association for the Rehabilitation of Respiratory Failure (ARIR) and the Italian Respiratory Society (SIP/IRS).

This joint statement is a Consensus Statement on Respiratory Rehabilitation in patients with COVID-19. It is based on the general experience so far in dealing with the disease and on the existing knowledge of the ITS – AIPO, ARIR and the SIP/IRS.

This joint statement represents an expert opinion of clinicians engaged in the field of RR, called – together with other specialities – to face with this emergency. It summarises the recommendations they consider most appropriate and urgent.

World Health Organization, 2020. Support for Rehabilitation Self-Management after COVID-19-Related Illness (No. WHO/EURO: 2020-855-40590-54571). World Health Organization. Regional Office for Europe.

This leaflet provides basic exercises and advice for adults who have been severely unwell and admitted to the hospital with COVID-19. It provides information on the following areas:

• Managing breathlessness
• Exercising after leaving hospital
• Managing problems with your voice
• Managing eating, drinking, and swallowing
• Managing problems with attention, memory, and thinking clearly
• Managing activities of daily living
• Managing stress, anxiety, or depression

Click here for document

Laviolette, L., & Laveneziana, P. (2014). Dyspnoea: a multidimensional and multidisciplinary approach. European Respiratory Journal, 43(6), 1750-1762.

Dyspnoea is a debilitating symptom that affects quality of life, exercise tolerance and mortality in various disease conditions/states. In patients with chronic obstructive pulmonary disease (COPD), it has been shown to be a better predictor of mortality than forced expiratory volume in 1 s. In patients with heart disease it is a better predictor of mortality than angina. Dyspnoea is also associated with decreased functional status and worse psychological health in older individuals living at home. It also contributes to the low adherence to exercise training programmes in sedentary adults and in COPD patients.

The mechanisms of dyspnoea are still unclear. Recent studies have emphasised the multidimensional nature of dyspnoea in the sensory–perceptual (intensity and quality), affective distress and impact domains. The perception of dyspnoea involves a complex chain of events that depend on varying cortical integration of several afferent/efferent signals and coloured by affective processing.

This review, which stems from the European Respiratory Society research symposium held in Paris, France in November 2012, aims to provide state-of-the-art advances on the multidimensional and multidisciplinary aspects of dyspnoea, by addressing three different themes:

1. the neurophysiology of dyspnoea
2. exercise and dyspnoea
3. the clinical impact and management of dyspnoea

Click here for review