Case study: Telerehab for COVID-19
Provided by Tom Sargeant, Senior Outpatient Physiotherapist, University Hospitals Plymouth NHS Trust
Situation:
64 year old male was admitted to hospital with COVID-19 infection. Due to severity of symptoms, he was quickly transferred to ICU and was an inpatient for four weeks. During his inpatient stay, the patient reported 3.5 stone in weight loss, pain and loss of sensation in his lower limb, and bilateral upper limb pins and needles. Symptoms on discharge included fatigue and breathlessness with basic functional activities of daily living and mobilising short distances (more than 10-15 metres). Due to the profound level of fatigue and breathlessness, even completing basic functional activities was very challenging. The patient lacked a lot of confidence and became very anxious at times. He felt that any activity would cause him difficulty breathing. He also required mid-day sleep to help manage his fatigue.
Actions: As the community respiratory team was unable to follow up the patient, it was deemed that all COVID-19 patients assessed by the COVID therapy team would be followed up via telerehab. This was to ensure every COVID-19 patient received rehabilitation, to monitor their recovery, and capture long term data on recovery and outcome measures.
Initially Attend Anywhere video assessments were arranged for patient follow-up. An initial appointment was made with the therapist who discharged the patient from hospital, who would understand the level of exercise tolerance, breathlessness and anxiety around activity.
Video assessment was chosen to help the patient engage in exercise therapy. This enabled assessment of the level of breathlessness the patient was experiencing during each treatment. Assessments were normally booked for mid-morning, giving time to rest from morning washing and dressing and before the mid-day scheduled nap. The patient was able to exercise with freedom of upper limb use and able to maintain positions of support of the upper limb to aid with breathlessness management. A set exercise progressive strengthening programme containing six exercises was issued. In addition to this a progressive walking programme and exercise diary were sent to the patient. The video assessment allowed us as clinicians to review the exercises and offer feedback on how to improve movement technique. These exercises were set and didn’t change to allow for continuity of treatment. This made it easy to progress the patient’s exercise tolerance (by just adding repetition or load to exercises) and monitor progression. It also helped the patient manage his anxiety of breathlessness around exercise much more easily.
After four months of treatment with improvements in function, strength and breathlessness, assessment and treatment transferred to telephone assessments. Telephone appointments enabled routine and outcomes to be monitored with ease. Initial video treatment and assessment, together with the set exercise programme, allowed for a smooth transition from visual telerehab to audio only.
Outcomes: The outcome of the treatment over 10 months of rehabilitation for this patient was very positive. Although the patient still experiences peripheral numbness, his breathlessness has improved and he has returned to independent mobility and functional tasks. The sit-to-stand in 30 seconds assessment improved greatly from 12 to 24. The patient was walking 10,000 steps daily with only moderate breathlessness on steep hills. His weight increased by 2 stone. He had returned to work and his hobbies of gardening and cycling. He reported his fatigue had improved and he no longer required naps and rest throughout the day. He was positive about his rehabilitation and understood he still had further progress to make. He was happy to self-discharge and felt confident about his future.
Reflection on telerehab: Telerehab offers a great way to assess and treat patients from a distance. It is a viable and effective option for offering movement therapy, even for patients with complex physical and emotional needs.
Having the ability to still see your patient and guide them through their rehab without them having to leave their home is very useful. Having video assessments over a series of sessions helps build a strong bond between the patient and clinician, despite never being in the same room. Telerehab still allows you to see and monitor improvements in movement, strength and function through the rehab process. It can offer reassurance to patients, ease anxiety of breathlessness and movement and help to build their confidence when returning to normal activity.
Feedback from clinicians and patients is very positive and the Attend Anywhere software is easy to use for both the clinician and patient. It has been proven that telerehab is a viable tool for the future. I look forward to continuing to use telerehab in my future practice.