Isn’t COVID-19 just a respiratory disease? If only that was true. We are good at treating respiratory infections. We have lots of drugs for viral, bacterial, parasitic, and fungal infections of the lungs. Most of them work really well! We also have several back-up treatments, inhaled medications, and adjuvant therapies (like rehab!) that make primary treatments even more effective. We are pretty darn good at treating respiratory infections. So, if COVID-19 was a respiratory disease only, we would have been all over that. We’ve been battling influenza in varying forms for over a century. We’ve stopped pneumonia in its tracks in even the most fragile patients. So, why haven’t we been able to put a cork in COVID-19? The answer is NO, it isn’t just a respiratory disease.
Yes, influenza can give you muscle aches. Yes, pneumonia, if left untreated, can lead to sepsis. But, COVID-19 causes severe physical damage to multiple organs and systems in your body. Particularly susceptible are the kidneys, heart, and brain. It is thought that their susceptibility is due to their expression of ACE-2 receptors, something this coronavirus is eager to find. Even the blood-brain barrier can’t keep it out, because this coronavirus destroys the barrier. The pancreas, skin, and blood vessels are also at particular risk.
We’ve talked about these topics quite a bit in the several previous posts. What do I have to offer that is new? I’m going to start treating COVID-19 like a multi-system disease. Just like we treat diabetes, just like we treat heart failure, just like we treat most other chronic diseases. Notice how I mention “chronic” disease? That’s intentional. That’s because we really don’t know what the long term effects of COVID-19 are going to be. Many people who didn’t require any medical intervention are several months out now on their infections and are still experiencing symptoms such as shortness of breath with little to no activity, and other symptoms that just keep lingering. Many experts feel that the damage this coronavirus causes to the endothelium (the lining of the vessels) will cause a long term increased risk for blood clots and strokes. As rehab providers, we need to know if someone has had COVID-19 because we will want to keep this in the back of our minds when performing our differential diagnosis.
Researchers are finding elevated inflammatory markers in people who have had COVID-19 including C-reative protein and interleukin-6. These are the same inflammatory markers we blame for so many long term inflammatory conditions in people who have end-stage renal disease (ESRD). Down to the cellular level, this disease changes our physiological function, interfering with the renin-angiotensin-aldosterone system (RAAS). This hormone based system also helps regulate inflammation, fluid levels, and blood pressures. People who have heart failure depend on regulated fluid levels in their body, so upsetting this already debilitated system would cause them serious harm.
Sure, we can treat the inflammation with dexamethosone. We can pump you full of antibiotics to prevent opportunistic infections. We can give you antivirals to slow the damage. We can thin your blood down to water and hope it still carries oxygen. We can treat the breathing problems with budesonide. Heck, we just can breathe for you. We can put you out so you don’t feel a thing. We can filter your blood for you. We can circulate your blood for you. We can flip you over so you breathe better. We can even wake you up just a little bit and walk you around the room attached to 30 different machines with a team of 8 or more highly skilled medical providers… But my goodness, we’ve never really had to do all of that at one time for one single person… And now we are doing it for thousands of people at hundreds of facilities all over the world.
Not a single one of those treatments is the answer. Every treatment that is hailed as the next “magic” answer to COVID-19 doesn’t address the whole disease. It may address part of it, like the early phase with minimal symptoms, or the asymptomatic phase, or the late acute phase, but nothing addresses all of it. We can definitely cut the mortality rate, which is a huge step, but no single treatment has been enough to prevent it all together. People who otherwise take these “hailed” medications for pre-existing medical conditions still contract COVID-19. The burden of this disease is huge and we have only seen a few months worth of damage.
Don’t get me wrong. I WANT there to be a cure or treatment or something that is effective at just wiping this thing out. We’ve done it with other viruses and bacteria through vaccines (like with Polio and Pertussis) or engineering controls like water sanitization (for Cholera). I’m also not saying a vaccine is the answer. What I’m saying is, I’m not ready to jump to conclusions about a single drug or treatment. Evidence, research, and time are important. We could find the greatest thing ever that treats everything perfectly, but then down the road we find it has side effects even worse than what we otherwise would have experienced. This has happened before (remember thalidomide?), and I don’t want it to happen again. Even if we come up with the perfect treatment or preventative tomorrow (fingers crossed!) we still have the people currently experiencing COVID-19 and its sequelae that need quality treatment.
All of this doesn’t mean we know nothing. Quite the opposite! We can actually predict with greater than 90% accuracy what someone’s clinical disease course will be, what levels of care they will need, and what treatments will be the best for them at each phase. We know that COVID-19 isn’t overall that deadly, but we do know that it is very damaging, and either one isn’t good. Polio was pretty damaging, too. We have three new studies confirming airborne transmission is possible and likely, especially in close confines and indoor environments. This research is what informs re-openings, mask wear, and other protective measures. I’d say we actually know quite a bit which is why we now know that this is a multi-system disease that needs to be treated like one.
Treating a Multi-System Disease
If we have a patient with diabetes, we don’t just treat their blood sugar. Even as rehab providers, we look at their circulation, their peripheral sensation, their central and peripheral balance, their cardiac function, their vision, and so many other aspects because we know that diabetes causes impairments in all of these domains. If we have a patient with heart failure, we never just look at their heart, do we? We know they have changes in their kidneys, their lungs, their vasculature, and their muscles… So we use test and measures to address all of these components. This is exactly How we need to be looking at survivors of COVID-19.
In the rehab world, what can we do to address COVID-19 as a multi-system disease? How does this change the way we screen, evaluate, and treat? You will need to look at the whole patient. Even in the outpatient setting, they are not just knee pain who had COVID-19 two months ago. If you are seeing patients in any setting who have had COVID-19, even tested positive but remained asymptomatic, you need to be looking at a number of things and the APTA has summed it up in 5 easy measures:
- Physical Function. Can we start out with, “Duh?”. The best way to do that is to use the Short Physical Performance Battery (otherwise known as the SPPB). This is a combination of three already standardized tests (timed chair rise, gait speed, and static balance) that give you raw scores and a sum score that is highly predictive of function. This is a great tool across functional levels and gives you a good amount of functional information to inform and direct your treatments. You can get all the deets here:
2. Strength. COVID-19 is known for causing weakness in the small muscle groups and the core. You may have a patient who can stand, but they can’t write their name. They may do a squat, but can’t walk 10 feet. Anyone who you meet that has had an ICU stay for COVID-19 is at risk for ICU acquired weakness (ICUAW). In that case, the Medical Research Council Sum Score (MRC-SS) is recommend for assessing strength. There are several articles listen in the references for the MRC-SS, but generally it is a combination of manual muscle tests of certain muscle groups.
Here is the source for this file: ResearchGate.
You can also learn more about scoring this was from this video:
3. Endurance. You’ve probably heard by now of someone who had COVID-19 and needed months of rehab. Or who didn’t go to the hospital but still gets short of breath walking short distances. Whether it’s due to long term immobility in the hospital or actual parenchymal damage to the lung tissue (or other body systems), endurance becomes significantly affected. The recommended test for endurance in people who have had COVID-19 is the 2 minute step test. This is a favorite of mine for people of all ages! I’ve used this for my ESRD patients, VAD patients, young athletes, and middle-aged adults. You can download the one-page here:
4. Cognition. We have talked several times about the effects COVID-19 can have on the brain. In this case, you should probably have a tool in your pocket to assess cognition. There are some specific cases of COVID-19 that are associated with delirium lasting longer than 72 hours. In the absence of other serious symptoms, you may find this patient in your clinic for any number of reasons or you may find that one of your current patients starts to develop some strange symptoms. The SLUMs (the Saint Louis University Mental Status Exam) is the recommended assessment to use in this case. You can access it for free here:
5. Quality of Life. Isn’t this what we should always be focused on? What can we do as rehab providers to improve someone’s quality of life? Unfortunately, we so often do not assess or quantify it, so it can be difficult to demonstrate improvement other than subjective report. The ED-5Q-5L is a simple questionnaire that can reliably quantify the quality of life for patients who have had COVID-19. Unfortunately, I can’t give you this one. However, you may be able to get it for free when you register with the company who created it. You can do that here: https://euroqol.org/support/how-to-obtain-eq-5d/ You can also view a sample of the document in English.
There is your tool box! You’ve got something for every major system. Obviously you can insert other objective measures you may need specific to your patient. For the time being, this is what we’ve got, and I think it’s a pretty strong set of tools. Hopefully, soon, we won’t need to worry so much about all of this, but until that day comes, we will continue to be the frontline against community spread, and the treatment for those with longterm medical complications regardless of their setting.
Have you used any of these tools for assessing patients after a run with COVID-19? Did you run in to any ceiling effects? Tell me about how they did and how they progressed in the comments!
If there is any treatment that I feel like gets used in a cookie-cutter fashion, it’s pursed-lip breathing. As much as I hate seeing this technique used for every single patient that has shortness of breath, it does have clinical usefulness. So let’s talk about how to implement pursed-lip breathing properly based on patient presentationContinue reading “Blow Out the Candles…”
I hope, at this point, you’ve all heard of the FAST acronym for identifying signs of a cerebrovascular accident (aka stroke). My in-laws even have a magnet on their fridge with a great comic strip describing the FAST acronym. I have run in to a couple different versions of it in the last few years,Continue reading “Emergency Response Screening”
So, who’s up for some bloodwork? Venipuncture, anyone? Finger prick, maybe? No..? Oh… Well, ok then. I’ll carry on. I know it may sound a bit crazy, but as a PT, I actually do some (very) minor blood work. I’m not trained as a nurse or phlebotomist or anything like that. Nope. Just some on-the-job-trainingContinue reading “PT/INRs: Helping Patients Manage their Anticoagulation”
American Physical Therapy Association. (2020). APTA Academies and Sections Consensus Statement: COVID-19 Core Outcome Measures. Retrieved from https://www.apta.org/contentassets/1a6e0ee7cd25403888d2959c1c8476cd/covid-19-core-outcome-consensus-statement-june-2020.pdf
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Connolly, B. A., Jones, G. D., Curtis, A. A., Murphy, P. B., Douiri, A., Hopkinson, N. S., Polkey, M. I., Moxham, J., & Hart, N. (2013). Clinical predictive value of manual muscle strength testing during critical illness: an observational cohort study. Critical care (London, England), 17(5), R229. https://doi.org/10.1186/cc13052
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Rikli, R.E., Jones, C.J. (1999). Functional fitness normative scores for community residing older adults ages 60-94. Journal of Aging and Physical Activity. 7:160-179. https://geriatrictoolkit.missouri.edu/cv/2min-step-rikli-jones.doc
Santarpia, J. L., Herrera, V. L., Rivera, D. N., Ratnesar-Shumate, S., Reid, S., Denton, P. W., Martens, J. W. S., Fang, Y., Conoan, N., Callahan, M. V., Lawler, J. V., Brett-Major, D M., Lowe, J. J. (2020). The Infectious Nature of Patient-Generated SARS-CoV-2 Aerosol. medRxiv 2020.07.13.20041632. Retrieved from doi: https://doi.org/10.1101/2020.07.13.20041632
Tsui, E. L. H., Lui, C., Woo, P. P. S., Cheung, A. T. L., Lam, K. W., Tang, T. W. , Yiu, C. F., Wan. C. H., Lee, L. H. Y. (2020). Development of a data-driven COVID-19 prognostication tool to inform triage and step-down care for hospitalised patients in Hong Kong: A population based cohort study. medRxiv. 2020.07.13.20152348 Retrieved from doi: https://doi.org/10.1101/2020.07.13.20152348
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