Pulmonary rehabilitation with vibration, and exercise therapy in a patient with COVID-19: a case report

Dyspnea, shortness of breath and inability to perform daily activities are the main concerns of COVID-19 patients. Physiotherapy can be an adequate reaction to those symptoms, that’s why scientists from Shahid Beheshti University (Tehran, Iran) presented the effects of pulmonary rehabilitation using a few physiotherapeutic techniques, with vibration among others, and exercise therapy in a patient with COVID-19. After completing the physiotherapy program they observed reduced COVID-19 symptoms and improved quality of life. Numerous indicators have improved, such as:

• general health (from 61 to 76 points),
• mental health (from 59 to 81 points),
• physical health (from 50 to 79 points),
• the mean severity of dyspnea has decreased (from 42 to 15 points),
• the difficulties in breathing has decreased (from 70 to 10%),
• anxiety level has decreased (from 56 to 47 points).

Prepared on the basis of:

Pulmonary rehabilitation and exercise therapy in a patient with COVID-19: A Case report. Arzani et al. Med J Islam Repub Iran. 2020;34:106.

Study population

Patient: female, age = 49 years, height = 161 cm, BMI = 21.2 kg/m2. No underlying disease (comorbid) and no smoking history.

On March 1, 2020, after 2 days of fever, dyspnea while performing moderate activities and non-productive cough at rest, the patient began presenting anosmia and taste disturbances. In the first week, the patient was not hospitalized. After the onset of diarrhea, hemoptysis and unbearable fever, on March 7, the patient was hospitalized (Tehran, Iran). On admission, blood pressure was 130/80 mmHg, heart rate 88 bpm, respiratory rate 25/min, peripheral blood saturation (SpO2) at rest was 92%, body temperature 38.6 °C. There were coarse breath sounds in both lungs. No changes were found during cardiac auscultation. Laboratory tests have shown an increased neutrophil count (2.8 × 10⁹/L) and a decreased lymphocyte count (0.9 × 10⁹/L). RT-PCR showed the presence of SARS-CoV-2 nucleic acid in the patient’s sputum. Chest computed tomography showed double-sided multilobar ground-glass opacification. The patient received oxygen therapy. Initially, a respiratory bag (8 l/min) was used, which was replaced with a nasal cannula on admission day 10. During the discharge, the patient breathed the surrounding air.

Test procedure

On the third day of admission to the hospital (March 10), physiotherapy began focusing on: dyspnea, shortness of breath, and the inability to perform daily activities such as eating. The patient underwent neurological (Glasgow Coma Scale) and pulmonary (Modified Borg Scale) assessment. The quality of life was assessed using Saint George’s Respiratory Questionnaire.

The physiotherapy program lasted 3 weeks and consisted of 2 training sessions a day (30 min on average). On the first day of admission to physiotherapy, because the patient was not fully aware, the program focused on passive motor exercises (15 min, twice a day), stretching the intercostal muscles (5 min, twice a day), chest vibrations (every 2 – 4 h for 5 min), whole-body exercises and the correct positioning of the patient’s body. Interventions in the first week were limited to passive and assisted-active exercises, and PNF (a form of stretching aimed at increasing muscle flexibility and range of motion), diaphragmatic breathing (5 cycles per session), pursed-lip breathing (5 cycles per session), vibration and whole body exercises (20 repetitions for each joint). Whenever it was possible, the patient was mobilized to a sitting or raised position – more favorable for ventilation. In addition, to increase exercise tolerance and improve cardiovascular health, the patient was encouraged to walk 50 m daily at her own pace while being oxygenated with a portable system. It seemed reasonable to limit any severe intervention in the acute phase as it could increase susceptibility to infection and jeopardize the stability of the patient’s vital signs. Accordingly, the patient’s vital signs and well-being were assessed and monitored throughout the entire period of physical therapy.

After 1 week of rehabilitation (March 17), as the patient could already perform all the above exercises on her own, the level of exercise difficulty was raised. At this stage, the patient was exercising on an ergometer (constant speed and low resistance, 2 times a day for 7 min) and was encouraged to exercise without oxygen focusing on breathing control. The patient used motivational spirometry every 2 h. The initial attempt was very low (around 500 ml), but the maximum inspiratory capacity reached 1500 ml. During this time, in the case of any breathing difficulties, the patient could use oxygen. After 2 weeks of hospitalization, the symptoms resolved and the patient was discharged home.

In the last week of rehabilitation, which was performed in an isolated space at the patient’s home, vital parameters were stable, and the patient had no restrictions in performing daily activities. The patient, on the other hand, claimed that her activity and efficiency were lower than before the disease, so the goal of rehabilitation was to achieve the level of independence presented before the onset of symptoms. In addition to the exercises mentioned in the previous steps, the rehabilitation activities included exercises in a real environment, such as climbing stairs (5 min), washing dishes (5 min) and cooking (5 min), and using motivational spirometry (10 breaths every 2 h) and facilitating the removal of pulmonary secretions by the medical device basing its action on stimulating respiratory vibrations (6 respiratory cycles every 4 h).

The patient underwent a total of 42 sessions of physical training over 3 weeks. A full assessment of their impact on the patient’s health was carried out before and after the program.

Use of vibration in the study

Manual chest vibrations and the Acapella respiratory rehabilitation device were used, as well as vibration training {the authors do not specify the parameters of the vibrations used; editorial note}. {Manual vibrations delivered by physiotherapists rely on making oscillating movements combined with applying pressure on the patient’s chest wall. Acapella is used orally. It facilitates the purification of pulmonary secretions, joining the advantages of various physiotherapeutic methods, including techniques of oscillatory positive expiratory pressure  and vibration generation. The lever swinging under the influence of the air stream inhaled into the device causes the air to vibrate, and these vibrations are transferred to the bronchial walls. The selection and use of the appropriate frequencies of air column vibrations can resonate the natural vibrations of the bronchial tree walls, strengthening them [see: Commentary in McCarren et al., 2006]. The discharge thus defragments the airways’ secretion more easily. Editorial note.}

Results

The results of the neurological, pulmonary and quality of life questionnaire assessments are presented in the table below.

Comment

As shown by previous studies, pulmonary rehabilitation regulates the respiratory cycle, improves ventilation and secretion clearance, and improves the patients quality of life. In addition, exercise therapy plays an important role in preventing muscle mass and strength loss in hospitalized patients. {Recently, in the rehabilitation of covid patients, the use of devices delivering therapeutic vibrations to replace physical activity has been proposed [Sañudo et al., 2020]. Especially taking into account the report showing the safe (and possibly muscle-activating) use of vibrotherapy in patients of intensive care units [Wollersheim et al., 2017]. Moreover, in the fight against COVID-19 there is a strong need to reduce the exposure of infected patients to direct contact with medical personnel and vibrating belts have already started to be used in mechanically ventilated patients with COVID-19, which, according to preliminary studies, help remove pulmonary secretions and increase blood oxygenation [Sancho et al., 2020]. Editorial note.}

This case report provides evidence for the implementation of physiotherapy, including vibrotherapy, in patients with COVID-19.

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