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Historically, rehabilitation professionals begin working with critically ill patients as part of their intensive care. Over the past few weeks, therapists have learned that waiting helps produce long-term benefits.
By IU Health Senior Journalist T.J. Banes, email@example.com
He sits on the side of his hospital bed at IU Health Methodist Hospital. To some that single move may seem simple. To David Balderas and his physical therapist, Kraig Brittain, that activity symbolizes progress. It also illustrates the necessity for rehabilitation taken at a slow pace.
Speaking through a Spanish interpreter Balderas said he feels like the work he’s doing with his therapists – getting out of bed and walking – are helping him get a step closer to returning home. He also said the encouragement and dedication of his therapists have made the greatest impact on his return to better health.
Balderas, 66, is typically strong. He works in demolition. Like many patients who contracted the coronavirus, Balderas lost that energy and stamina when he was hospitalized for several weeks.
He was driving to a worksite in Cincinnati when he first began feeling sick and weak. He was so tired that he had to stop and take a break on his drive home. When he arrived back in Indianapolis, Balderas was transported by ambulance to IU Health Methodist Hospital. He is one of hundreds of patients treated at IU Health hospitals for COVID-19.
An integral part of that treatment is rehabilitation – including physical, occupational, and speech therapy.
“In the normal world, occupational and physical therapy is part of an order set for ICU patients. So we were involved pretty early in their hospitalization for COVID. Like everyone else, we needed to step in and design a plan based on how ill they were and the availability of the personal protective equipment,” said Elizabeth Altenburger, director of rehabilitation adult acute care. Within days, a coordinated effort between all therapists resulted in an online training for 350 team members.
“It was an opportunity for us to share our initial experiences with these patients and to involve outpatient therapists and others who would eventually be working with these patients,” said Altenburger.
The biggest discovery: Unlike other ICU patients who actively participated in therapy as a means to an end – hospital discharge – patients with COVID-19 were unaware of their limitations.
“It’s the first time in my career where I’ve told a patient not to work so hard. “I’m usually pushing them but we quickly learned that mobilizing COVID-19 patients can cause them to relapse,” said physical therapist Lynne Brittain. She described two strong male patients who felt well enough to begin arm and leg exercises and within minutes experienced drops in their blood pressure and oxygen levels.
“With the most severe cases, they are having difficulty holding their heads up and even pulling their shoulders back or holding their smart phones to communicate with family members. They get exhausted quickly. Even when they are physically able to walk they don’t have the lung capacity to support activity,” said Brittain.
Physical Therapist Aubrey Little describes it as “a limited amount of gas in their tank.”
“They are presenting with low physiological reserve. They are a very fragile population. Anything we do from elevating their head to rolling them in bed uses up some of that gas in their tank,” said Little. “They don’t necessarily feel the changes in their vital signs so we have to be very conservative, taking things slowly and stopping often for breaks.”
COVID-19 patients have faced other challenges as well including a risk of kidney disease and delirium.
IU Health Nephrologist Dr. Brent Miller has said, “If you don’t have a severe manifestation of COVID, your risk of kidney disease is very low. But if you’re in ICU with COVID, and especially if you’re on a ventilator, your risk may be as high as 15 percent.” Dr. Miller said it is debated if COVID’s impact on the kidneys is a reaction to the dysfunction of other organ systems, or if it is a direct effect of the virus on the kidneys. Physicians are seeing that the virus attacks the respiratory system and the heart that can impact the kidneys.
Typically, therapists begin working with patients while they are still on ventilation, but with COVID-19 patients, therapists are taking things more slowly.
Even after surviving intensive care and moving toward therapy, many patients show signs of delirium. Along with all of these interventions, the patients rely on healthcare providers to help them communicate with absent family members, and in some cases, help them relearn certain skillsets.
Therapists say that even when patients’ bodies are moving their minds aren’t always keeping up.
“The executive functioning isn’t rebounding as quickly as typical.
We don’t really know what causes the delirium – the lack of oxygen, or the complexity of the virus,” said Altenburger. “ICU delirium is real but this has extended. They can say, “My name is this and I’m at Methodist Hospital but they don’t recall other details.”
What does all this mean for patients like Balderas? He wants to go home, take a long, hot shower and eat a good home-cooked meal.
“Physical therapists have a unique role in deciding when patients are safe to leave and still function on safe levels of oxygen,” said Brittain. “I want to be totally confident that when they go home they won’t have a readmission. Historically, I’d feel my role was to safely get the patient out of bed and walking and now it’s completely different. I need to consider exactly what is needed – do they need to walk up a driveway? What exactly do they need to accomplish to live safely and comfortably at home?”
For many patients that therapy doesn’t end when they are discharged from the hospital. Many COVID patients will continue with outpatient rehabilitation for weeks and months.