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Physical Therapy Considerations of Neurologic Presentations in COVID-19
Hosts
Kim Levenhagen, PT, DPT, WCC, CLT, FNAP
Sharon L. Gorman, PT, DPTSc
PresentersAkanshka Verma, PT, MA, NCS
Sowmya Kumble, PT, MPT, NCS
Morgan Lopker, PT, DPT
Sponsors
Objectives • Recall a brief overview of the pathophysiology of COVID-19 as it
relates to the neurologic system• Discuss emerging evidence related to neurologic impairments found
in patients diagnosed with COVID-19• Consider the importance of vital sign monitoring when working with
neurologic patients with this condition• Review assessment of delirium, weakness and other impairments
found in this population• Discuss treatment strategies
Neurologic Implications of COVID-19 PathophysiologyVital Signs and Hemodynamics
Presented by Morgan Lopker PT, DPT
Senior Physical Therapist, Critical Care and Education LeadLos Robles Regional Medical Center Thousand Oaks, CA
Vice-Chair of the Academy of Acute Care Physical Therapy Practice Committee
Proposed COVID-19 Staging
Siddiqu 2020
Neurologic Sequela of Sepsis
Sonneville 2013
.
From Delirium to Dementia
Chung 2020
Olfactory Nerve Entry Point for COVID-19
Wu 2020
Pathways of Potential Virus Associated Neurologic Injury and Impairment
Wu 2020
ACE2 Receptor Mediated COVID -19 Neurologic Injury
Baig. 2020.
Cytokine Storm to Coagulation Cascade
Zhou 2020, Lippi 2020
Cerebral Hemodynamics
Bouzat 2013, Silvio Taccone 2013, Wilson 2016
Factors Affecting Cerebral Blood Flow and Intracranial Pressure
Bouzat 2013. Silvio Taccone 2013, Wilson 2016
Persistence of COVID -19 Neurologic Sequela
Chung. 2020
References • Baig AM, Khaleeq A, Ali U, Syeda H. Evidence of the COVID-19 Virus Targeting the CNS: Tissue Distribution, Host-Virus Interaction,
and Proposed Neurotropic Mechanisms. ACS Chem Neurosci. 2020:0-3. doi:10.1021/acschemneuro.0c00122• Bouzat, P., Sala, N., Payen, J. et al. Beyond intracranial pressure: optimization of cerebral blood flow, oxygen, and substrate delivery
after traumatic brain injury. Ann. Intensive Care 3, 23 (2013). https://doi.org/10.1186/2110-5820-3-23• Chung H-Y, Wickel J, Brunkhorst FM, Geis C. Sepsis-Associated Encephalopathy: From Delirium to Dementia? J Clin Med.
2020;9(3):703. • Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A
meta-analysis. Clin Chim Acta. 2020;506(March):145-148. doi:10.1016/j.cca.2020.03.022• Siddiqu HK, Mehra MR. COVID-19 Illness in Native and Immunosuppressed States: A ClinicalTherapeutic Staging Proposal. Journal
of Heart and Lung Transplantation. doi: 10.1016/j.healun.2020.03.012 • Silvio Taccone F, Scolletta S, Franchi F, Donadello K, Oddo M. Brain Perfusion In Sepsis. Curr Vasc Pharmacol. 2013;11(2):170-186.
doi:10.2174/157016113805290263• Sonneville R, Verdonk F, Rauturier C, et al. Understanding brain dysfunction in sepsis. Ann Intensive Care. 2013;3(1):1-11.
doi:10.1186/2110-5820-3-15• Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. J Cereb
Blood Flow Metab. 2016;36(8):1338–1350. doi:10.1177/0271678X16648711• Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun.
2020;(March):1-5. doi:10.1016/j.bbi.2020.03.031• Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a
retrospective cohort study. Lancet. 2020;395(10229):1054-1062. doi:10.1016/S0140-6736(20)30566-3
STREAMLINING YOUR ASSESSMENT FOR COVID -19 PATIENTS Sowmya Kumble, PT, MPT, NCS Clinical Resource Analyst Johns Hopkins Hospital
• Chart review • Medications• Assessment of cognition • Cranial Nerve Exam• Vital signs• Neuromuscular/ Musculoskeletal System • Integumentary system
Chart review • Co-morbidities (old stroke, any other NM disorders, seizures, dementia,
psychiatric, HTN, DM)
• Baseline functional status
• Lab values (troponins, D-dimer)
• Orders – O2 titration
• Imaging (CT/MRI brain)/EEG reports if done
• Medications – CNS side effects of sedation/paralytics
Medications • Sedative-analgesics
– Benzodiazepines (Midazolam)– Opioid analgesics (Fentanyl/Propofol) – Antipsychotics (Haloperidol) – α2-adrenoceptor agonists – Dexmedetomidine (Precedex)
• Neuromuscular blocking agents – Vecuronium
• Vasopressors (if <60 mmHg of MAP) – Norepinephrine(Levophed)
• Inotropes w/ vasodilator effect– Dobutamine
Cognition • Beyond AOx3• Arousal
– Richmond Agitation Sedation Scale (RASS)
• Speech/Communication • Safety awareness
+4 Combative +3 Very Agitated+2 Agitated+1 Restless0 Calm and Alert-1 Drowsy; eye opening & contact ≥
10 secs-2 Light sedation; eye open &
contact < 10 sec-3 Moderate sedation (Movement or
eye opening to voice; no eye contact)
-4 Deep sedation; no response to voice, eye open to physical stimulation
-5 Unarousable
RASS Score
Delirium“Disturbance in consciousness and cognition that develops over a short period of time (eg, hours to days) and tends to fluctuate during the course of the day”
• Risk factors – Predisposing factors (baseline)– Precipitation factors (hospitalization –related)
The American Psychological Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV
Risk factors for Delirium
AgeHTN
Pre-existing cognitive deficit/Dementia
Alcohol use Depression
Severity of illness Respiratory disease Need for mechanical
ventilation Medications (sedatives –
Benzos; opiates)Hypotension
Sepsis Fever
Lack of daylight Isolation
Lack of visitorsImmobility
Sleep deprivation
ICU Delirium - Screening• Screening tools:
– Confusion Assessment Method (CAM)- ICU– Intensive Care Delirium Screening Checklist (ICDSC)
1. Acute change or fluctuating course of mental status over the past 24 hours
2. Inattention:Squeeze my hand when I say the letter ‘A’SAVE A HAART
3. Altered level of consciousness (Current RASS)
4. Disorganized thinking: 1. Will a stone float on water?2. Are there fish in the sea?3. Does one pound weigh more than two 4. Can you use a hammer to pound a nail?
YES
>2 errors
RASS = 0>1 error
CAM-ICU positive Delirium present
RASS ≠ 0
CAM-ICU
www.icudelirium.org
Types of Delirium • Hypoactive
– Lethargic/drowsy/infrequent spontaneous movement• Hyperactive
– Agitated/combative/risk for self-extubation/falls/line dislodgment• Mixed
Cranial nerves • CN I – Smell • CN II – Asymmetrical pupil size; reaction to light) • CN III, IV, VI- Oculomotor (eye movements) • CN V - Facial sensation, if awake and oriented • CN VII- Facial movements/sensation of tongue• CN VIII- Vestibular/ hearing • CN IX and X - taste/hoarseness of voice• CN XI – shoulder shrug (Trapezius) & head rotation (SCM) • CN XII – Tongue movement
Vital Signs • Breathing pattern
• Accessory muscle use
• O2 saturation /O2 requirement
• Blood pressure (Mean arterial pressure)
• Heart rate (Tachycardic PE)
• EKG abnormalities
• RPE scale, if alert/oriented
Neuromuscular/Musculoskeletal• Observation - Abnormal posture/positioning
– foot drop /shoulder subluxation• Tone • ROM • Muscle strength (Brachial Plexus Injuries/PNI/ ICU acquired
weakness/Stroke/Guillain-Barré Syndrome):– Symmetrical vs Asymmetrical– Proximal vs Distal – UE vs LE
• Sensation – Touch/Proprioception• Coordination • Balance – static/dynamic/ functional
Integumentary System • Positioning
– Prone• Pressure relief
Functional mobility & hemodynamic stability• Positional changes
– Raising the head of bed gradually– Continuous monitoring for tolerance to position change
• O2 saturation – time to recover– additional O2 needs to recover (Titrate as needed if ordered)
http://cardiopt.org/pdf/pubs/Supplemental_Oxygen.pdf
Take Home Messages• Oxygenation & perfusion is vital for brain function
– PT role in early detection of neurological manifestations
• Adverse effect of prone positioning
– Screen for peripheral nerve injuries
• As much info in very little contact time
• COVID-19 is NOT JUST a pulmonary condition
– “Patient as a whole”
PT Management of Patients with
COVID-19 Akanshka Verma, PT MA
NCS
REHAB MANAGEMENT OF COVID-19 patients
Goals of a rehab program:
● reducing the complications associated with a prolonged ICU stay● improving tolerance to activity● improve cognitive and emotional domains, in order to
○ promote the quality of life and ○ facilitate home discharge
REHAB MANAGEMENT OF COVID-19 patients
● Acute ICU phase ○ Assistance with proning to improve oxygenation
○ Prevention of skin breakdown
○ Management of ICU delirium/ encephalopathic changes/CNS changes due to metabolic disarray
○ Management of cognitive changes
Importance of diagnosing and managing ICU delirium● Delirium is defined as a disturbance of consciousness, with inattention accompanied by a change in cognition or
perceptual disturbance that develops over a short period (hours or days) and fluctuates over time.
● 60-80 percent of ICU patients on mechanical ventilation experience delirium
● One in three patients with ARDS experiences PTSD a year after the medical event● Assessment of delirium
Confusion assessment method for ICU- CAM
Factors that increase risk of delirium● HTN● Smoking● Pre Existing dementia● Obesity● Precipitating factors are hypoxia, metabolic disturbances, withdrawal syndromes, dehydration, and
medications.○ Loss of sleep awake cycles, sleep deprivation, excessive noise, lighting
https://ohiohospitals.org/OHA/media/OHA-Media/Documents/Patient%20Safety%20and%20Quality/Hospital%20Improvement%20Innovation%20Network/Additional%20Topics/Iatrogenic%20Delirium/1-24-19-MHA-and-OHA-Learning-Network.pdf
Management of Post ICU DeliriumABCDEF (A2F) bundle
COMPONENT
A Assessment & Management of pain
B Spontaneous Awakening trial & Spontaneous Breathing trial
C Choice of analgesia & sedation
D Delirium: assess, prevent & manage
E Early mobility & exercise
F Family engagement & empowerment
Management of Post ICU Delirium
● Management must be specific to Patient population
● Repeated reorientation of patients
● Provision of cognitively stimulating activities
● ROM exercises
● Early mobilization with caution
● Timely removal of noxious factors- restraints, catheters
● Delirium specific multidisciplinary education of staff
ICU delirium [Internet]. Nashville, VUMC Center for Health Services Research. c2013; [accessed on 8 Aug 2016]. Available from: www.ICUdelirium.org.
REHAB MANAGEMENT OF COVID-19 patients
Acute non-critical care management:
● Closely monitor for worsening of respiratory status & orthostatic changes
● Low intensity, interval training
● Outcome measures
● Cognition
● Subjective measures of fatigability
Modified rate of perceived exertion
https://thefittutor.com/rpe-scale/https://www.cdc.gov/physicalactivity/basics/measuring/exertion.htm
REHAB MANAGEMENT OF COVID-19 patients
The rehab phase ● Understanding of patient specific impairments & activity limitations
● Aerobic exercise: for those cases with respiratory/motor problems and physical deconditioning,- incorporate functional tasks
● Strength training for peripheral muscle weakness
● Static and dynamic balance training for balance dysfunction
● Neuropsychological training: counselling sessions, psychological support, and cognitive training.
REHAB MANAGEMENT OF COVID-19 patientsExercise Prescription
· Modeo Self-care and functional trainingo Aerobic – postural change, supervised ambulationo Breathing with overhead activities.· ★ Pair inhalation and exhalation patterns with movt to enhance the motor task and improve
oxygenation· Intensity
o Consider using RPEo Correspond SpO2 ratings with RPE scale in order to be independent with pacingDurationo Begin with intermittent bouts lasting 3-5 minutes as toleratedo Rest periods at patients’ discretion
Aim for shorter rest than exercise – 2:1 ratio· Frequency
o Consider all disciplines that interact with patients
REHAB MANAGEMENT OF COVID-19 patients
Patient Education
❖ · Instruct to watch for signs of hypoxemia at home
❖ · Energy conservation techniques
❖ · Walking program
❖ · Field questions as you are able re: diagnosis and disease progression
❖ · Handouts
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