The coronavirus pandemic is changing many aspects of health care. Hospitals are not allowing visitors, patients are delaying or refusing routine care and many services are switching to digital formats through the end of the public health emergency. This includes physical and occupational therapy services (PT, OT). However, as COVID-19 patients return home from the intensive care unit (ICU), many need PT in order to return to normal life.
Post Intensive Care Syndrome (PICS) is a term coined in 2012 to describe the illnesses people experience after a stay in the ICU. PICS can manifest as problems with physical function, cognition and mental health. PICS cases are expected to increase as a result of the current pandemic.
“The average age for an ICU patient is 45 to 55,” James Smith, a physical therapy professor at Utica College in Utica, New York, said in an interview with HomeCare. “This is an age group used to working and playing with their kids. More seniors are passing away from COVID-19, but as the disease progresses, they will also need care.”
A Host of Issues
Before COVID-19, more than 4 million adults were released from the ICU each year. Intensive care survivors may have problems with walking or driving, cognitive issues with memory and executive function or with symptoms of depression, and post-traumatic stress disorder.
These issues associated with PICS track with problems Vinod Somareddy is seeing with patients entering the Reddy Care Physical and Occupational Therapy practice in Great Neck, New York.
“They have a lot of fatigue, a lot of weakness; a loss of function. They cannot do things that they could do before. They have a lot of respiratory problems and loss of endurance,” Somareddy said. “And because of their comorbidities, some of their other issues are exacerbated. So if you have a person with a previous fall injury, their balance is affected more. They are less able to move on the stairs,and they don’t want to after they get home. Those complaints don’t go away.”
For a patient recovering from any critical illness, not just COVID-19, rehab is vital as they work to regain the ability to perform the activities of daily living. A stay in the ICU should be a “yellow flag” for physical therapists, said Patricia Ohtake, associate professor in the department of rehabilitation science at the University at Buffalo.
Ohtake and Smith and other colleagues recently published a study, “Home and Community-Based Physical Therapist Management of Adults with Post–Intensive Care Syndrome,” in the Physical Therapy Journal. In it, they reported that after a patient is in the ICU, physical therapists need to look for physical and cognitive problems that may affect how the person communicates or performs recovery tasks, Ohtake said.
“Get a baseline of where a patient is after a hospitalization,” Somareddy said. “It could be a head injury, a fall—whatever. With COVID-19, you’re going to assume the patient has been immobile. This is going to center around the patient’s safety. Measure their baseline. The endurance may not be there. They may have a really good day one day, but we want to make sure we use those functional outcome scores as a tool. As we know, if they have a medical issue, we address and deal with that. But our job is to make sure we get them back to their normal activities of daily living (ADLs). We want to work every day to improving those baseline ADLs. It’s one thing for a patient to say I feel good, and the therapist to say you look good, but another to see that the functional score has improved and they can walk 300 feet to their kitchen.”
Problems and issues associated with PICS may not go away in a few weeks or months following an ICU stay, even with physical therapy. There is a baseline of recovery in the first year, Ohtake said, but she cited studies that showed some patients walking at only 60% to 70% of their normal capacity after the first year.
So what should physical therapists and others do following an ICU stay?
“The primary goal surrounds making sure the patient is safe and gets back home. And is safe and functional in the home,” said Somareddy. “Some family members are concerned that if the patient goes to a nursing home or assisted living facility and [another injury] happens and they can’t see their family, what happens? We are seeing a concerted effort to get the patient home and able to do their own activities of daily living. That means they can do the self-management activities, the sit-to-stand activities, and other ADLs.”
The Centers for Medicare & Medicaid Services has penalized hospitals and post-acute care settings when patients returned to the hospital within 30 days of release. With a focus on patient safety following an ICU stay, Smith recommends focusing on compensatory strategies such as adding walkers and toilet lifts to the home. Therapy provided in the home setting allows therapists to better compensate for barriers to recovery.
“In the hospital, you see patients can use a walker, but in the home, the walker doesn’t fit through the door of the bathroom. The homecare therapist will take the door off the hingesnand put a shower curtain up to keep people out of the hospital. It’s not a unique pandemic issue. I think homecare providers have been dealing with that for decades, but now the challenge is if a surge of people are coming home to provide the care they need,” Smith said.
PICS can affect family members, as well.
“These physical, cognitive and mental health problems continue,” said Ohtake. “They may need help feeding, dressing, getting off the toilet. This will add to the physical and mental issues for the family. It can be overwhelming.”
Family caregiver participation in therapy is vital to the recovery of a patient post-ICU stay, however.
“Most people don’t have a lot of time to devote to be a therapist to their mom or dad,” said Somareddy. “But if there are three exercises that are essential, encourage and be involved. A key to the therapy working is how motivated the patient is.”
“I would encourage families to reach out if therapy hasn’t been part of the discharge processes,” said Ohtake. “Reach out to primary care providers. 90% of these patients have been discharged, but they haven’t had physical therapy, and they don’t realize our providers can help.”
Pulmonary Recovery for COVID-19 Patients
Many patients hospitalized with COVID-19, have been ventilated and sedated. It’s a respiratory illness, and many patients with respiratory illnesses benefit from pulmonary rehabilitation to help strengthen the lungs.
“Pulmonary rehab is usually classified for chronic obstructive pulmonary disease and emphysemas and other respiratory illness,” Sommareddy said. “You have to build into the treatment model therapy to build up the lungs. It’s about knowing how to build up breathing and build up capacity.”
Sommareddy acknowledged that some patients with pre-existing respiratory illness are concerned that if infection does occur, they will be sicker. The tools of pulmonary rehab can help build up endurance and build confidence to prevent the illness, he said.
Many physical therapy practices were closed at the beginning of the pandemic due to the close contact patients have with their providers. Many offices switched to a telehealth model for those patients who would benefit from it.
“Some patients are doing very well with it, and trying to get the best therapy they can get,” Sommareddy said about telehealth. “They know they need to do something to address their issues. For some patients, it’s been helpful. But for some, it’s not been something that helps. They need more intervention.”
Sommareddy said only a small percentage of Reddy Care’s patients have benefitted from telehealth therapy.
“Having the personal interaction with your therapist is something that many value. But also, they want to create a safe environment. We do have to use it and we do have to be cognizant that we need to do whatever it takes to get therapy to the patient,” he added.
On the advocacy front, Ohtake and Smith pointed out, patients that needed care last year need care this year as well. In the age of the Patient Driven Groupings Model, homecare agencies need to prove their value, including in the therapy realm. And, therapy services will continue to be needed to keep patients healthy and at home.