We conducted the evaluation by a two filters analysis. The first one consists of evaluating the deficiencies linked with the COVID-19 infection and the associated ARDS, through a specific COVID-19 aggregation of scales. The second one targets the motor function using the Frail’BESTest [6] in order to orientate the clinical reasoning.
Level 1: The specific COVID-19 evaluation
In front of the heterogeneity of COVID-19 clinical pictures, we tried to propose a global summery including several clinical examinations. The available literature [7-8] spots a pulmonary typical deficiency associated with several new clinical scripts (ARDS, Psychomotor dis-adaptation syndrome, acquired pneumopathy, acquired neuromyopathy, etc.). The aggregation of scales was done in a transdisciplinary rehabilitation approach to screen all the important aspects consecutive to the infection. Tests were retained for their usability, their reliability and their validity.
- Social and behavioral functions are evaluated with the RAMSAY score [9] and the RASS scale [10].
- Some items of the Hamilton scale (HDRS) are used to measure the psychological and emotional state [11].
- The simplified cardiac and respiratory evaluation allows to measure the usual parameters with the mMRC dyspnea scale [12] and the Borg scale [13]. The peak cough flow rate (PCFr) is also measured [14-15].
- In accordance with the loss of mass frequently described [8], the body Mass Index is noted. Swallowing function is evaluated with simple tests.
- Frailty detection is based on several tests showing a good sensitivity : the gait speed measure [16], the chair test in one minute [17], the functional reach test [18] and the grip strenght test [19].
- Neuro-motor functions are evaluated by the PFIT-scored [20] and the MMRC [21-22]. A few items of the Mini Motor Test [23] and the BESTest [24] allow a large vision of the patient.
- A binary analysis of statesthesia and tact are proposed in addition to the other senses.
- About sensitivity, a double assessment including statesthesia and touch [25] is done.
The evaluation synthesis of Mr P is displayed on Figure 2a and 2b.
Level 2: Reasoning with the Frail’BESTest.
The Frail’BESTest has been developed to make it possible to include frail older adults when using a systemic evaluation [6]. Therapists can therefore directly manage therapeutic intervention for different types of balance deficiencies. Overall, 6 sub-systems have been addressed: 1: anticipations, 2: reactions, 3: locomotion, 4: sensorial orientation, 5: biomechanical constraints and 6: asymmetric gait.
Diagnostic
Mr P, a 93 years old patient, presents a respiratory dysfunction linked with a Covid-19 infection (saturation at 91% with 7 liters Oxygen supplementation), subsequent effort incapacity, and posturo-motor deficiencies. Motor automatisms are impaired, and several articular and muscular constraints remain. Mr P seems enlisted in a frailty process, leading to an increased dependency, an impossibility to return at home, and a relative social isolation.
Therapeutic intervention
The protocol was carried out in agreement with legal and international requirements (Declaration of Helsinki, 1964). Mr P was informed about the publication project and gave their written consent before the evaluation.
Mr P followed a rehabilitation program which included mainly physical therapy and nutritional monitoring. He received one session of physical therapy per day. This session lasted in average 30 minutes. Considering the physiotherapy diagnosis of Mr P. as well as the age-specific lung physiology of the patient [26], some cardiopulmonary rehabilitation exercises allowing both maintenance of ventilator functions and the improvement of hematosis can be proposed. During all of these exercises, precautions, red flags and stop criteria indicated in the HAS Quick Response [27] should be followed.
The next paragraph will show the aims and exercises samples that have been proposed to Mr P.We would like to improve both transverse abdominis and diaphragm by active, functional and resistive treatment including threshold systems, hypopressive exercise and functional ventilation during efforts [28–30]. In order to limit physiological impairment, some exercises including thoracic movement with arms, chest and spine mobility are introduced during global therapy in both ways : inhale and exhale [31-32]. In order to improve oxygenation and prevent congestion, ventilation should be harmonized throughout the lung territories and mucociliary clearance should be promoted. Thus, high-volume ventilator-type work that includes tele-inspirational holds while avoiding the specific collapses associated with senescence. For example, exercises of type EDIC, ITLA (Inspiratory Technical for Lifting Atelectasis), Elpr, ACBT with open glottis are proposed [33-34]. Concerning rehabilitation with effort, it is necessary to increase the ventilatory threshold, to improve the muscular function and decrease dyspnea. This will also improve hematosis and oxidative metabolism. An early and progressive cardiopulmonary rehabilitation program is established and based on Borg scale [35-36]. For Mr P. it includes optimal loading, aerobic work by paliers as well as endurance. This program mainly uses functional exercises such as treadmill walking (between 60-80% of the TM6 or of the chair-test or top toes test) [37]. It also seems important to prevent dysphagia in the medium term and to optimize the use of the functions of the nose (warm, filter and humidify the air). So, nasal ventilation and correction of the tongue position is essential. For example mindless nasal ventilation and tongue palate position is followed and lingual resistive exercise and sensitive work are proposed. In a final perspective of patient’s autonomy, throughout the rehabilitation, an education to the perception of effort, the use of the Borg scale, the self-assessment of his respiratory capacities and the criteria of alerts is carried out [38].
On the other hand, in connection with the systemic evaluation of the balance function and motor frailty of Mr P, several sensory-motor exercises are proposed. To improve the efficiency of posture-movement coordination, self-paced perturbations of balance were worked with speed and variability [39]. For example, Mr P. must reach a colored target on the ground as quickly as possible once the physiotherapist has indicated the color he has hit. To reactivate postural adaptations and fall avoidance reactions, Mr P performs exercises working on extrinsic imbalances (unpredictable balance perturbation [40]. For example, Mr. P had to react to manual pushes from the physiotherapist. In order to improve muscular power, functional muscular exercises were performed in a closed chain and with a time constraint [41]. For example, Mr. P had to go up and down a step to the beat of a metronome. In order to regain physiological ankle mobility and to enhance the rolling of foot during walking, active mobilization exercises were carried out during physiotherapy sessions and also by the patient independently in his room [42]. To reduce the podal dependency, Mr P performed static and dynamic balance exercises on different ground textures (e.g. standing on foam, walking on a mat, walking outside in the grass...). Finally, exercises integrating the work of spatial and temporal parameters of the walk and changes of direction were carried out. These exercises were aimed at improving walking kinetics and would participate in the evolution of the technical walking help.
Follow up and outcomes
The 4 assessments performed by the COVID-19 specific evaluation showed an overall improvement of the patient in several functions. In terms of psychological and emotional state, the anxiety with regard to oxygen dependence disappeared. Indeed, at the initial assessment the patient had 7L of oxygen in the high concentration face mask. At the final evaluation, he had only 1L of oxygen left in the nasal cannula. Pulmonary auscultation, which initially revealed a lack of ventilation associated with congestion of the middle and distal airways, also improved. Final auscultation is evaluated without particularities. The assessment of cognitive and behavioral functions remained unchanged over the course of the 4 assessments. Initial clinical observations did not show impairment of these functions. The initial preliminary assessment of the vascular and cutaneous system had shown the presence of a stage 1 pressure ulcer (National Pressure Ulcer Adivory Panel Stage Classification) behind the ears due to the oxygen mask. At final evaluation, the pressure ulcer was no longer present. No vascular disorders have occurred during the hospitalization. Moreover, there was no significant change in swallowing function, as Mr. P did not present any swallowing problems.
The changes in the scores of the quantitative outcomes of the different functions are summarized in Table 1.
|
Section
|
Item
|
Evaluation n°1
|
Evaluation n°2
|
Evaluation n°3
|
Evaluation n°4
|
|
Date
|
27/04/2020
|
20/05/2020
|
29/05/2020
|
8/06/2020
|
|
Cardio-respiratory
|
Oxygenotherapy (L.min-1)
|
7
|
2
|
1
|
1
|
|
Dyspnea : mMRC score
Dyspnea : Borg score
|
rank 3
7/10
|
rank 3
6/10
|
rank 3
6/10
|
rank 3
4/10
|
|
SpO2 (Oxygen saturation) at rest
|
91%
|
92%
|
92%
|
94%
|
|
Sp02 after walking
|
84%
|
86%
|
88%
|
86%
|
|
Respiratory frequence
|
24
|
22
|
20
|
19
|
|
Chest expansion / Ventilatory assymetry (cm)
|
4
|
5
|
5
|
6
|
|
Level of muscular strength
|
Diaphragm = 3/5
Transversus abdominis = 3/5
|
Diaphragm = 3/5
Transversus abdominis : = 3/5
|
Diaphragm = 3/5
Transversus abdominis : = 3/5
|
Diaphragm = 4/5
Transversus abdominis : = 4/5
|
|
Frailty
|
Gait speed (m.s-1)
|
NE
|
0,33with rollator
|
0,4 with rollator
|
0,57 with rollator
|
|
Grip strenght (kg)
|
26
|
30
|
30
|
32
|
|
One min Sit to Stand Test
|
8
|
12
|
12
|
15
|
|
FRT (cm)
|
20
|
20
|
21
|
23
|
|
Functional and neuromotor
|
PFIT-scored
|
5,9/10
|
5,9/10
|
6,4/10
|
7,1/10
|
|
mMRC
|
44/60
|
50/60
|
56/60
|
56/60
|
|
BESTest III-10 : Mounted on tiptoe
|
Score 2
|
Score 2
|
Score 2
|
Score 2
|
Table 1: A summary table on the differents evaluations with specific Covid-19 evaluation
The 4 assessments of Frail’BESTest show an improvement in the score of some subsystems. The results are summarized in Table 2.
|
FrailBestTest
|
Initiale evaluation
|
Intermediate evaluation (number one)
|
Intermediate evaluation (number two)
|
Final evaluation
|
|
Date
|
27/04/2020
|
20/05/2020
|
29/05/2020
|
8/06/2020
|
|
System A : Anticipations
|
3
|
3
|
3
|
4
|
|
System B : Reactions
|
0
|
0
|
0
|
1
|
|
System C : Locomotion
|
NE
|
1
|
2
|
2
|
|
System D : Sensory orientation
|
2
|
2
|
2
|
2
|
|
System E : Biomechanical constraints
|
2
|
3
|
3
|
4
|
|
System F : gait symetry
|
4
|
4
|
4
|
4
|
|
Total score
|
11
|
13
|
14
|
18
|
|
Gait speed (m.s-1)
|
NE
|
0,33 with rollator
|
0,4 with rollator
|
0,57 with rollator
|
Table 2: A summary table on the differents evaluations with FrailBestTest