Physiotherapy
QUESTIONS WE HAVE ANSWERED
What are the recommended physiotherapy outcome measures to use with Covid-19 patients in an out-patient post-COVID clinical setting?
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.
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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.
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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.
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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
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Question
- What is the current best practice when working as a CBT therapist in primary care?
- In light of the new strains of Covid 19 and the most recent information, is it still recommended to wear a face shield and maintain 2 metres distance from the patient?
- What is a safe session duration?
Short Answer
Recent updates of Irish guidance have reiterated that masks must be worn in healthcare facilities when a distance of 2 metres cannot be maintained. However, the guidance does not specifically address if masks need to be worn if persons are greater than 2 metres apart. Surgical masks are recommended for health workers within primary care practices while face coverings are recommended for patients entering a primary care practice. An updated rapid evidence summary by the HSPC indicates that face coverings are preferable to visors/shields to reduce transmission of COVID-19, though the evidence is of low quality. However, there are circumstances where a face covering may not be appropriate and may affect quality of care. In these circumstances a visor/shield may be used provided that it extends from above the eyes to below the chin and from ear-to-ear. The role of room ventilation is increasingly acknowledged and some guidance exists on increasing ventilation though this is dependent on context. Recommendations are not made about safe session duration.
The content of this document is correct as of 02/02/2021.
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Question
How can a person who is a ‘close contact’ without their own transport safely travel to a COVID-19 testing centre? Are there any specific arrangements for students or healthcare workers? Can they use public transport, taxi or is there any arrangement with the ambulance centre to support this?
Short Answer
A person who is a ‘close contact’, without their own car, should ask one person that they live with to drive them to the testing centre. If the ‘close contact’ does not live with anyone who has a car they should ask someone who they have been in close contact with very recently to drive them. They should follow the HSE guidance on how to safely travel in a car in such a circumstance. A person who is a close contact should not use public transport, this includes using a taxi service. There are no special arrangements in place for students or healthcare workers.
The content of this document is correct as of 10/11/2020.
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QUESTION
Do I need to wear a mask if maintaining a 2m distance in a treatment room while delivering face-to-face CBT in Primary Care?
Short answer
The National Public Health Emergency Team (NPHET) has recommended that healthcare workers use a surgical mask for all patient care activities when a safe distance (2m) cannot be maintained. This implies that when a 2m distance can be maintained a mask is not necessary. However, the NPHET guidance does not state this explicitly and does not address the issues of room size/occupancy or duration of contact. The European Centre for Disease Prevention and Control considers maintaining a 2m distance in a closed environment, such as a treatment room, as low-risk for exposure to COVID-19. The HSE Health Protection Surveillance Centre state that in low-risk circumstances, where wearing a mask may impact on patient care, a clear face visor is an acceptable alternative.
The content of this document is correct as of 30/09/2020.
These documents were used to answer this question:
- Health Protection Surveillance Centre (2020). Interim Guidance on Infection Prevention and Control for the Health Service Executive 2020 v1.2. HSE: September 2020.
- Health Protection Surveillance Centre (2020). Guiding principles for Infection Prevention and Control when returning to routine General Practice during pandemic COVID-19 v2.1. HSE: July 2020.
- European Centre for Disease Prevention and Control (2020). Public health management of persons having had contact with cases of novel coronavirus in the European Union. ECDC: February 2020.
Dr Liz Kingston, member of the RapidInfo4U Panel of Experienced Clinicians and Lecturer at the University of Limerick, with a clinical speciality in infection prevention and control, was consulted to answer this question.
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What is the impact of achieving adequate nutrition in the rehabilitation phase post COVID-19 infection?
Short Answer
At this time, there is no evidence on the impact of adequate nutrition in the rehabilitation phase post COVID-19. There is also limited evidence for the impact of adequate nutrition in the prevention and treatment of COVID-19. However, given the broader evidence on the impact of nutrition on recovery from infectious diseases, guidelines highlight the need to assess malnutrition in COVID-19 patients and to develop an appropriate plan to ensure necessary energy, protein, vitamin and mineral intakes.
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How long do taste changes or loss remain post COVID-19? What is the impact of same?
Short Answer:
Research indicates that about 1 in 3 COVID-19 patients will experience taste changes or loss and that for the majority this dysfunction will last 7 to 14 days. It is not yet clear how long it will take those patients with persistent taste dysfunction to recover. Research to date has included only short-term follow-up protocols, following patients for four to eight weeks. As with everything in the COVID-19 era evidence is constantly accruing and more research is needed to determine both the average length of recovery time for persistent taste dysfunction as well as the impact of such a dysfunction overtime on the patient. Existing literature on taste dysfunction (unrelated to COVID-19) has found that loss of taste can be detrimental to both the physical and mental health of a patient. There are currently no treatments recommended by researchers for loss of taste produced by the COVID-19 virus.
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Question
When cleaning areas between patients are detergent wipes (e.g. Sanicloths) required or will a general detergent spray and disposable tissue suffice?
When disinfecting areas between patients are disinfectant wipes required or can we use disinfectant spray and disposable tissues?
Short answer
The HSE Health Protection Surveillance Centre guidelines do not stipulate that wipes are required to clean or disinfect areas between patients. Disposable tissues, cloth, or paper towels are sufficient to use in conjunction with the appropriate detergent solution and disinfectant.
The content of this document is correct as of 06/11/2020.
This response was based on HSE Health Protection Surveillance Centre Interim Guidance on Infection Prevention and Control for the Health Service Executive 2020 v1.2. Available here.
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Question
Is there sufficient evidence to warrant a change in the established position (i.e. NICE guidelines of June 2020) regarding vitamin D for the prevention or treatment of COVID-19?
Short answer
No, there is insufficient evidence to warrant a change in the established position (i.e. NICE guidelines of June 2020) regarding vitamin D for the prevention or treatment of COVID-19. Best practice remains maintaining recommended levels of Vitamin D, which may include supplementation of vitamin D in groups at high-risk of deficiency.
The content of this document is correct as of 17/09/2020.
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QUESTION
- To what degree are people with Long COVID presenting with dysphagia and/or voice difficulties?
- To what degree are mildly symptomatic / asymptomatic patients post COVID presenting with dysphagia and/or voice difficulties?
SHORT ANSWER
Long COVID has not yet been well-studied and research is underway in this area. Many of the studies of dysphagia and voice difficulties are observational or prospective with small sample sizes and varying lengths of follow-up. Furthermore, the evidence for dysphagia/voice disorders in long-COVID is limited at this point. Studies mainly focus on dysphagia and voice difficulties following acute respiratory distress syndrome (ARDS) and/or the associated respiratory support interventions such as intubation and tracheostomy. The limited evidence suggests people with who have been hospitalised for COVID-19 and particularly, those who have experienced ARDS and undergone associated medical interventions, are at increased risk of dysphagia and/or voice difficulties. There is also preliminary evidence that dysphagia can be addressed through rehabilitation, therefore, reducing long-term effects. In addition, there is insufficient evidence to assess the degree to which mildly symptomatic or asymptomatic patients present with dysphagia and/or voice difficulties post COVID-19.
The content of this document is correct as of 05/02/2021.
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Question
Could you please provide clarity on the proper disposal of PPE?
What type of bin should be used? Can certain types of PPE be disposed in domestic bins (e.g. masks)?
Short Answer
If PPE is worn with a person who is known or suspected to have COVID-19 then it should be disposed of in a healthcare risk waste bin (yellow). If a healthcare risk waste bin is unavailable, the following procedure should be followed:
- All items of PPE should be disposed of into a plastic bag
- The bag should not be filled more than three quarters full
- The bag should be securely tied and placed inside another second, plastic bag (double bag)
- The bag should be stored securely for 72 hours and can then be disposed of with general domestic waste
If PPE is worn in the absence of a specific known risk of COVID-19 it can be discarded immediately as general domestic waste. There is no distinction made between different types of PPE in terms of disposal procedures.
The content of this document is correct as of 11/12/20.
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Question
1.Can a Classroom Feeding Observation for Dysphagia take place within a Pod?
2.When conducting a Classroom Feeding Observation for Dysphagia do parents of children in the same Pod as the patient need to be informed of, and consent to, the observation?
Short answer
1.Yes, assuming local and national COVID-19 guidelines are followed including PPE and social distancing, a Classroom Feeding Observation for Dysphagia can take place within a Pod.
2.Yes, assuming local and national COVID-19 guidelines are followed including PPE and social distancing, a Classroom Feeding Observation for Dysphagia can take place within a Pod.
The content of this document is correct as of 18/09/2020.
This response was based on the Department of Education COVID-19 Response Plan for Reopening our Primary and Special Schools, version 2, published in August 2020. Access this document here.
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QUESTION
What is the current guidance for Occupational Therapists practicing telehealth?
ANSWER
There are a number of best practice guidance documents currently available. We have summarised the information and guidance from the Irish COVID-19 Occupational Therapy in Acute Hospitals Interest Group, the Association of Occupational Therapists of Ireland, the World Federation of Occupational Therapists, the American Occupational Therapy Association and Occupational Therapy Australia (OTA).
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Question
Can the below tests be administered via telepractice?
- Beery-Buktenica Developmental Test of Visual-Motor Integration
- Detailed assessment of speed of handwriting (DASH)
Answer
Yes, both Beery and the DASH have publisher recommendations for administration via telepractice. Detailed instructions for the DASH can be found here and detailed instructions for the Beery can be found here.
Both tests are published by Pearson. The DASH telepractice information is available on the Pearson UK website but it does not appear on their US website. For the Beery, vice versa, the telepractice information is available on the Pearson US website and does not appear on their UK website.
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Question
What is the impact on return to work for patients with COVID-19 who have been hospitalised?
Short Answer
In Ireland, 3,676 people have been hospitalised because of COVID-19. There is no information on the consequent work status of these individuals. This is also the case on the global stage. There are indications from small scale studies and research on similar diseases (SARS & MERS) that some individuals hospitalised with COVID-19 will experience delayed return to work. Fatigue and breathlessness are the most common post-discharge symptoms. Scientists and professional bodies are calling for occupational therapists and other allied health professionals to prepare for the surge in demand for services but more research is needed to determine the long-term consequences of a COVID-19 hospitalisation and its impact on return to work.
The content of this document is correct as of 08/10/2020.
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Question
Essential oils have been use for decades for the treatment of minor ailments. Each particular essential oil has their specific properties from antiviral, antimicrobial, anti-fungicide, antibacterial and so on. Is there any evidence that essential oils ease respiratory symptoms or respiratory distress for patients with COVID-19 if used alongside or in conjunction with medical treatment?
Short Answer
Research on the antiviral properties of essential oils are at the early stages. Recent reviews have found no trials that evaluated the clinical efficacy of essential oils on respiratory symptoms caused by coronavirus in humans. Additionally, current studies fail to provide adequate information on the toxicity of essential oils and safe dose information.
The content of this document is correct as of 28/01/2021.
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Are visors a safe alternative to face masks for patients who cannot communicate with healthcare professional who is using a face mask?
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QUESTION
Is there a mandatory requirement to set aside vacant rooms to be utilised in the event of a COVID-19 outbreak in a residential care facility?
Will there be financial provision or grant to the centre to cover the cost of having vacant rooms for this purpose?
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GUIDELINES
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.
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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.
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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
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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
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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.
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The purpose of this document is to update the 1999 ATS
Consensus Statement on dyspnea.
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This is an American Thoracic Society Statement from 2012 providing an update on the Mechanisms, Assessment, and Management of Dyspnea
Click here for statement
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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.
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CONTENT FROM SCIENTIFIC JOURNALS
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
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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:
- the neurophysiology of dyspnoea
- exercise and dyspnoea
- the clinical impact and management of dyspnoea
Click here for review
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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
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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
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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
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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
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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
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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
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OTHER REPUTABLE REPOSITORIES & USEFUL CONTENT
The World Confederation for Physical Therapy, now World Physiotherapy, represents more than 670,000 physiotherapists worldwide through its 122 member organisations. They have developed a hub for information and resources about COVID-19 relevant to the physiotherapy profession which is available here.
Physiopedia are a not-for-profit organisation whose mission is to improve global health through universal access to physiotherapy knowledge. They have resources related to the role of the Physiotherapist in COVID-19 available here
The Irish Society of Chartered Physiotherapists (ISCP) is the national, professional body representing over 3,000 Chartered Physiotherapists in Ireland. They provide helpful resources for members. Visit their website here.
A Coping with Breathlessness poster courtesy of the Dept of Physiotherapy, Pulmonary Rehabilitation, University Hospital Limerick.
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A Progressive Muscle Relaxation script for Pulmonary Rehabilitation courtesy of the Dept of Physiotherapy, University Hospital Limerick.
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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
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Click here for an opinion piece “Coronavirus: how physiotherapists are helping patients recover” written by Julie Broderick, Trinity College Dublin and Catherine L. Granger, University of Melbourne for Trinity News and Evetns
The article discusses some of the problems that physiotherapists can assist with when people are in hospital with COVID-19.
RapidInfo4U is part of the Irish Government’s national coordinated research and innovation response to the COVID-19 pandemic. RapidInfo4U is funded by a Health Research Board COVID-19 Pandemic – Rapid response funding award and managed by the Health Implementation Science and Technology cluster at the University of Limerick.
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