Rehabilitation program and challenges in managing hospitalized COVID-19 patients: a case series from Egypt

Background The COVID-19 pandemic urged all healthcare providers to collaborate to defeat this mortal infection. SARS-CoV-2 almost hits the respiratory system and may have subsequent serious complications like pulmonary embolism and multi-organ damage. Objective To illustrate the rehabilitation program challenges encountered by physiotherapists in clinically managing hospitalized COVID-19 patients. The goal was to preclude the need for invasive mechanical ventilation and to improve the patient’s oxygen saturation and general health. Methods In this retrospective case-series study, we described the physiotherapy strategies implemented for 14 COVID-19 patients during the hospitalization period at an Egyptian governmental quarantine hospital. Results The rehabilitation program was customized by physiotherapists to accommodate the specific circumstances, conditions, and acquired complications of individual patients. Patients were under the care of physiotherapists in both the COVID ward and ICU. Overcoming challenges such as patient reluctance, co-morbidities, and the effects of aging was a task faced by these healthcare professionals. Consequently, the program had to be modified to suit the unique needs of each patient. These tailored programs encompassed techniques such as percussion, positioning, range of motion, circulatory exercises, and respiratory exercises. The patients exhibited positive responses to their designated physical therapy program, experiencing improvements on various levels based on the progression of their individual cases. Conclusion Physiotherapy has a major role in improving patient complications after being infected with COVID-19. In this desperate pandemic era, physiotherapists gave hospitalized patients support both psychologically and physically.


Introduction
Severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) is a fearful novel virus known for its rapid global dissemination.The primary clinical presentation of coronavirus disease 2019 (COVID-19) predominantly involves acute respiratory distress syndrome (ARDS), alongside symptoms such as fever, cough, myalgia, mucus hypersecretion, dyspnea, and gastrointestinal manifestations [1][2][3].The World Health Organization (WHO) has reported approximately 6 million fatalities worldwide attributed to COVID-19, with around 24,222 deaths recorded in Egypt between January 3, 2020, and March 8, 2022 [4].The pathogenesis of COVID-19 involves initial invasion of the lung upper airway, then it spreads through the alveolar epithelium resulting in impaired gas exchange and consequently respiratory failure [5].It is believed that COVID-19 is associated with hypoxemia and an increased risk of thromboembolic events [5,6].Moreover, immobile hospitalized COVID-19 patients are particularly vulnerable to coagulopathy which may result in severe complications such as deep vein thrombosis, myocardial infarction, pulmonary embolism, and stroke [6].The severity of COVID-19 is classified by the WHO and the Egyptian Ministry of Health and Population based on specific criteria as shown in Table 1 [7,8].
An Egyptian prospective study reported that 51.5% of hospitalized COVID-19 patients were moderate cases and added that mild cases were 25.4%, and severe or critically ill cases were 23% [9].
Physical therapists play a crucial role in the early rehabilitation of COVID-19 patients by implementing interventions like early mobilization, respiratory care, and functional exercises to enhance lung function, reduce complications, improve quality of life (QOL), and expedite recovery.Therapeutic strategies employed by physical therapists include controlled breathing techniques, thoracic expansion exercises, airway clearance methods, respiratory muscle strength training, cough exercises, diaphragmatic training, and stretching routines according to evidence-based guidelines prior to the COVID-19 era and guidelines introduced during the COVID-19 pandemic as stated in the review conducted by Battaglini et al. [1,10].There is growing concern regarding the potential development of weakness in hospitalized COVID-19 patients due to their prolonged immobilization and underlying health conditions [11,12].
In Egypt, during the COVID-19 era, various physical therapy (PT) research studies with different designs were conducted.For instance, a quasi-experimental study in Assuit focused on the impact of telehealth PT programs on post-COVID-19 patients [13].Another study involved PT educators about online teaching via a questionnaire [14].Additionally, a randomized controlled clinical trial was conducted at Ain Shams University Hospital compared the outcomes of one versus two PT sessions per day [15].Furthermore, a research study was carried out on children with cerebral palsy via a questionnaire answered by their parents [16].
Despite these studies, there is limited understanding of the role of physiotherapists in treating COVID-19 patients, as highlighted in a letter to the editor [17].To address this gap, this case series study was undertaken in Egypt to provide a comprehensive description and was the sole case series conducted during that period in Egypt.The primary objective of this study was to assess the impact of PT interventions on hospitalized COVID-19 patients, specifically focusing on improving respiratory function and functional status.

Study design and setting
This case series was uni-central at Al-Agouza Hospital in Egypt.The research protocol was deemed exempt from Institutional Review Board (IRB) approval.

Participants
Physiotherapists and investigators retrospectively documented 14 confirmed COVID-19 cases using RT-PCR testing on nasopharyngeal swabs.These patients were hospitalized between July 20, 2021, and November 4, 2021, and all of them have recovered and been discharged home.The selection criteria included patients with extended and consistent lengths of stay (LOS) to enable comprehensive follow-up and documentation.

Physiotherapist intervention
Physiotherapists established the optimal PT program to improve the patient's status besides pharmacological and nutritional lines of treatment.The cases referred to PT intervention commonly presented with symptoms such as dry cough, productive cough with difficulty in clearing mucus hypersecretion, shortness of breath (SOB), weakness, fatigability, and immobility.
The intervention schedule comprised daily sessions, including holidays, starting from the referral date, except in cases where patients were medically unfit for a session due to conditions like resistant hypertension, extreme fatigue, or patient refusal.Each session lasted approximately 15-30 min, tailored to each patient's tolerance and response to treatment.Physiotherapists monitored patients using a pulse oximeter to assess blood oxygen saturation levels (SpO 2 ) and improvements in oxygen The PT program was customized for each patient based on their condition and requirements, with a focus on respiratory and mobility rehabilitation (Fig. 1).

Respiratory rehabilitation
The respiratory rehabilitation program consisted of the following:

Airway clearance techniques
One of the most common issues confronted by COVID-19 patients is the management of bronchial secretions.Airway clearance techniques (ACTs) are a set of methods for removing excess secretions from the airway.The goal is to reduce airway obstruction in order to re-expand the collapsed areas of the lung, improve gas exchange, and decrease the inflammatory response.Rarely is a single technique used in respiratory physiotherapy, but rather a combination of different ACTs.Clearance of the airways is performed with the lowest possible incidence of side effects and adverse events [18].The following are ACTs that are commonly used with COVID-19 patients that do not involve the use of devices.
Postural drainage It is a positioning technique where gravity assists in mucus collection and drainage from peripheral to central airways, then coughing and forced expiration aid in getting rid of this mucus [18].
Manual techniques They are specific forces applied using hands to the patient's chest with consideration to the patient's endurance: Percussion (cupping or clapping) A successive rhythmic strokes introducing kinetic energy to the chest wall using cupped hands on the required lung segment during the patient's inspiration and exhalation.If the patient feels discomfort, this process is stopped immediately [18].
Vibration It refers to performing rapid oscillatory manual pressing in the intercostal space along the ribs direction during the patient's expiration using the therapist's flattened hands [18].

Active cycle of breathing techniques
Active cycle of breathing techniques (ACBTs) consist of three phases performed in a defined order: breath control, thoracic expansion exercises (TEE), and forced exhalation technique (FET) [18].
a Breathing control encourages tidal volume breathing, with relaxed neck and shoulders and the diaphragm contracting for inspiration, to calm the patients who feel breathless, agitated, or anxious.
Patients are encouraged to breathe in via their noses to humidify, warm, and filter the air breathed in and to lessen the turbulence of the inspired flow.b TEE enhances lung expansion by inhaling slowly and deeply through the nose (larger amounts than the tidal volume).The breath should be held for 3 s at the end of inspiration and then exhaled passively without forcing the air out.This deep breathing technique helps to open up and expand the blocked collateral airways and loosen the mucus in the lungs so that the patient can clear the secretions.c The FET is the last part of the cycle where the patient combines a tidal volume respiration and forced expiration, often known as huffs.The maximum expiratory airflow is determined by the huff length and the force with which the expiratory muscles contract, limiting the collapse of the airways.
ACBT can be performed in various postures, however, most potent when done in a vertical position.ACBT can also be done in conjunction with manual techniques (percussion or vibrations) to enhance the clearance of mucus.

Range of motion exercises
Depending on the patient's condition, various joint range of motion exercises, including passive, active-assisted, active, or resistive exercises, are carried out, to maintain or enhance joint integrity, range of motion (ROM), and muscular strength [2].

Bed mobility exercises
These are tasks the patient can perform while confined to a bed to avoid developing acquired weakness, stiff joints, and bed sores.
Bed mobility exercises include sitting out of bed and sitting while maintaining balance.When the patient is able to engage in antigravity exercises, the patient will start cautiously with sit-to-stand and walking practices [2].

Physiotherapy cases
The cases' presentation summary is described in Table 2.
Case 1 A 49-year-old female patient had ARDS and was hospitalized.She experienced headaches and bone aches for a week prior to admission.She also developed fever, cough with blood-tinged sputum, dyspnea, and desaturation.She had a past medical history of cardiomyopathy, hypertension (HTN), diabetes mellitus (DM), and obesity.
The main challenge was persuading the patient to participate in the PT intervention maneuver.Attempting to control her breathing pattern triggered coughing attacks and induced dyspnea.Initially, therapists tamed her breathing pattern so that coughing was not triggered.Second, because she was obese and had difficulty moving in bed on her own, therapists assisted her in changing positions in bed.Further, the patient went through the rehabilitation program of respiratory exercises (RE) that helped her avoid prolonged coughing.To develop the proper breathing pattern, we instructed her to take short breaths through her nose and exhale slowly through her mouth.Second, we instructed her to take longer breaths and to stop before the urge to cough arose.As the patient fulfilled the precedent procedures, therapists encouraged her to hold inspiration for better air distribution so that the SpO 2 would not drop.The patient's initial response to therapy was slow, but by the first week, therapists managed to help her get out of bed and do walking exercises.Her SpO 2 moved from 96% on an oxygen mask of 15 L/min to 97% on a nasal cannula of 1 L/min and 97% on room air (RA) on discharge day.
Case 2 This 60-year-old male was presented with an acute onset of dyspnea and cough that started the day before hospitalization.He had a history of fever for 9 days, which resolved 5 days before admission.His SpO 2 at RA was 88%, with a chest computed tomography (CT) score of 4, indicating a severe COVID-19 case.The patient started PT sessions 2 weeks post-admission as he developed SOB and found it difficult to move around without falling off SpO 2 .The therapists proceeded RE while shifting positions from sitting to standing and walking across the room.Controlled RE involved taking deep breaths and holding them for a few seconds.Also, the patient was instructed to breathe slowly whenever he attempted to move so that a cough would not be triggered.
On discharge, the patient was able to move freely without desaturation and regained his normal mobility and activity levels.
Case 3 This 81-year-old male patient had a stroke that caused right hemiplegia.He also suffered from cough, SOB, and dyspnea.His age and neurological status were a challenge to us.We started mainly by giving him RE and chest percussion to stimulate his chest and improve his breathing.A program to rehabilitate the patient's right side was given in the form of facilitatory neurological techniques to the right upper and lower limbs and strengthening exercises to the left upper and lower limbs to assist his mobility.Afterwards, by the end of his stay in the hospital, the patient was able to move with assistance

Case 9
After being critically ill for 12 days suffering from fever, bone aches, and anorexia, this 55-year-old female was hospitalized after failure of home therapy.She reported dyspnea, tachypnea, and excessive productive cough.She was admitted to the ward for 4 days in which she received a PT intervention of breathing, coughing exercises, and percussion to promote chest clearance.The therapist noticed that the patient had a shallow breathing pattern that triggered coughing and stress.The therapist taught her how to breathe properly and how to stop the coughing episodes with effective expectoration.The therapist also used relaxation techniques to prevent chest muscle spasms caused by prolonged coughing.
The patient was transferred to ICU due to desaturation as her SpO 2 reached 85-88% when on high-flow NRM.She was treated in the ICU for 3 days till her status was stabilized and returned to the ward on a simple mask of 15 L/min with SpO 2 of 95%.She started a moderate mobility program in bed so she could shift positions frequently without desaturation, then progressed to get up from the edge of the bed and begin walking.
Further, after a prolonged reclined position caused her muscle problems, she performed standing and sitting exercises to correct her posture.Also, she was instructed to do position-changing and weight-shifting exercises when she began to have gluteal bed sores.At discharge, her SpO 2 on a simple mask at 1 L/min was 98%.Without using the mask, she was able to return to her bed while maintaining her SpO 2 .She learned how to do the respiratory and mobility exercises at home to maintain her progress after testing negative for COVID-19.
Case 10 A 71-year-old man was hospitalized with symptoms of dyspnea, hypoxia, and a chest CT of score 5.He had a dry cough that turned productive after a few days.His SpO 2 on high-flow NRM was 94%, and a week later, when his CPAP SpO 2 turned 86%, he was transferred to the ICU for 3 days.His SpO 2 was fluctuating, as he changed his position.The SpO 2 fell to 80% when he lay on his right side experiencing dyspnea and SOB, while his SpO 2 on the NRM was 94% when he lay on his left side.So, the patient received RE to enhance chest expansion, improve diaphragmatic breathing, and control breathing in different positions.He also received percussion followed by cough stimulation exercises to promote chest clearance.Alongside his RE, a mobility program was given to maintain good ROM for all his joints as he had bone and muscle aches, which were common symptoms among COVID patients.Upon achieving a blood SpO 2 level of 92% while using a simple mask at 1 L/min during the final 3 days of hospitalization, along with enhancements in breathing patterns and mobility, the patient was discharged with instructions to maintain his current level of mobility and engage in regular RE.
Case 11 A 71-year-old woman was referred to our hospital suffering from COVID-19 pneumonia, respiratory distress, and hypoxia after first being admitted to another facility with tachypnea and dehydration symptoms.She was admitted to the ICU on CPAP and then transferred to the ward on high-flow NRM and SpO 2 of 92%.Her main complaints were dyspnea, SOB as well as limb edema.She underwent a PT program from the second day of her admission to the ICU and continued her sessions in the ward till her discharge.The PT program included mobility exercises for the ULs and RE to improve chest expansion and breathing patterns.She also received a circulatory exercise to reduce the edema in her lower limbs (LLs).At discharge, her SpO 2 was 97% on a simple mask of 1 L/min without dyspnea but still experienced SOB with exertion.So, she was advised to resume her PT after discharge to enhance and maintain her recovery.
Case 12 A male patient, aged 33, who had bronchial asthma (BA) without regular medication, developed fever, cough, dyspnea, and hypoxia for 6 days.He was hospitalized with severe respiratory distress and SpO 2 of 77% on NRM with irritability and agitation.He stayed in the ward for 4 days before desaturation forced a transfer to the ICU.His SpO 2 remained unchanged; therefore, a CPAP mask was used to raise his SpO 2 from 91 to 96%.And when it reached 94% on NRM at rest but decreased on exertion to 88%, he was referred to PT to tame his breathing pattern while on NRM and CPAP.As the patient was frequently agitated, which affected his breathing, therapists taught him relaxation techniques.He practiced deep breathing and slow, alternate movements of his UL and LL.His irritation subsided as his SpO 2 rose, and his breathing pattern was restored.Furthermore, the patient responded better to PT sessions and began mobility exercises in and out of bed (the distance which could be reached with a mask on).
When his SpO 2 reached 96% on an intermittent nasal mask, his only complaint was the muscle pain he felt while coughing.Finally, he performed all out-of-bed mobility exercises like walking around his bed several times with his mask off and applied UL and LL ROM exercises free of pain.
On discharge, he was instructed to increase his exercise gradually, monitor his SpO 2 , and avoid getting too tired to prevent post-exercise injuries given his current weakness and recent recovery from COVID-19.
Case 13 A diabetic, hypertensive 70-year male patient was hospitalized with SpO 2 of 88% on RA after suffering from hypoxia, dyspnea, and fever for 5 days.
He spent 2 days in the ward, but he had resistant HTN and needed ICU transfer.Once his blood pressure and condition improved, he returned to the ward on a simple mask of 15 L/min and 95% of SpO 2 .
He started PT in the ICU while he was on a high-flow NRM.He performed respiratory and circulatory exercises, which were sometimes interrupted due to a rise in his blood pressure, but were resumed afterwards.In the ward, he continued with RE and gentle percussion to clear his chest from excessive productive cough.He also did mobility exercises including active assisted exercises for both UL and LL and upgraded to walking around his bed with a mask on.His SpO 2 improved on the last day of stay to 96% on a simple mask of 3 L/min.Finally, he was discharged with a recommendation to maintain a daily physical activity to avoid another poor health condition as being a diabetic and hypertensive patient.
Case 14 This 75-year-old patient had cough, dyspnea, and SOB for 5 days prior to admission.His past medical history included chronic atrial fibrillation, DM, HTN, and cardiomyopathy.He was admitted to the ICU for a day due to urine retention.His SpO 2 was 88% on RA and 95% on a 3 L/min nasal cannula.After 1 day of admission, he was transferred to the ward as his SpO 2 had improved to 99% on a simple mask 5L/min.The patient began PT after moving to the ward.The therapist used gentle percussion to help him expel sputum and cough.He struggled to cough because of general weakness.He complained, "I feel the urge to cough and phlegm in my throat that I cannot clear." The therapist taught him how to cough effectively by taking a deep breath, holding it as long as possible, and then exhaling forcefully while coughing.This helped him clear his lungs of sputum.The therapist also positioned him in different postural drainage positions to facilitate expectoration.The patient did exercises to enhance his circulation, breathing pattern, and general mobility.He started to move with and without his mask for the time to just make a turn around his bed.At his discharge, he had 95% of S02 on RA, and no signs of desaturation or irregular breathing while walking.He was instructed to maintain a reasonable level of mobility and activity to enhance his progress and maintain his general wellness.

Discussion
This case-series study aimed to introduce the impact of physiotherapists on the respiratory and functional status of COVID-19 patients.PT was initially mandatory for only severe and critically ill cases to minimize infection transmission [7].However, physiotherapists' roles have evolved into an integral component of the multidisciplinary healthcare team, contributing to the overall wellbeing of the majority of patients.Physiotherapists' interventions ranged from patient education to respiratory and mobility rehabilitation.Among the 14 cases examined, there were 8 male and 6 female patients, predominantly aged between 49 and 83, with two cases aged 34 and 37. Most patients were admitted in critical or severe conditions, commonly presenting with symptoms such as productive cough, dyspnea, and hypoxia.The most reported comorbidities included DM, HTN, and obesity.Six cases required ICU admission without the need for mechanical ventilation, with three cases utilizing CPAP as the highest level of oxygen support.
The length of hospital stay range for all cases was 8-49 days, with each case requiring between 2 and 48 PT sessions.
Cases 3 and 7 had a history of stroke, where PT played a crucial role in addressing neurological or mobility issues, enhancing their ability to perform activities of daily living efficiently.A case report supported this view, demonstrating improved respiratory and functional abilities in a COVID patient with post-stroke motor neurological dysfunction following PT procedures [19].Furthermore, a systematic review revealed a reduced risk of complications with early PT intervention in hospitalized stroke patients [20].
The PT clinical practice guidelines did not initially recommend PT intervention for COVID patients with a dry cough in order to mitigate the potential transmission of the infection [7].However, within our hospital setting, the PT program was recommended for patients complaining of a dry cough (cases 2, 3, 6) alongside those with a productive cough.Dry cough causes irritation and soreness in the chest wall muscles, which may worsen COVID-19 symptoms.Notably, some studies have highlighted the efficacy of PT intervention in attenuating the progression of COVID-19 in patients experiencing a dry cough [19,21,22].
Cases 9 through 14 required ICU admission, where PT facilitated regular chest and mobility exercises to mitigate ICU-acquired weakness resulting from prolonged bed rest [23].Thus, PT intervention improved patients' respiratory function by guiding them to promote more efficient breathing, which relieved their irritability [24,25].Furthermore, PT had a vital role in keeping critically ill cases away from deconditioning to the stage requiring mechanical ventilation (case 8) [11].Nevertheless, a study conducted at the ICU of the Public Health Center in China identified that a subset of ICU patients exhibited compromised physical and respiratory functions upon discharge.Specifically, the peak expiratory flow rates and maximal inspiratory pressures were found to be lower than the anticipated outcome values, indicating the necessity for extended rehabilitation interventions [26].

Limitations
Our study faced some limitations as it was done on a small number of patients in a single hospital setting.Further, the pandemic caused a shortage of PPE for physiotherapists, which limited the provision of PT to only serious cases.Additionally, the admission severity of the patients was not accurately assessed, as some of them were transferred from other hospitals and did not have SpO 2 measurements on RA due to mask support.Physiotherapists also did not use standardized scores and scales to evaluate the patient's progress.

Strengths
The risk of cross-infection between physiotherapists and patients was minimized by avoiding the use of respiratory and mobility exercise equipment.Safety for physiotherapists was accomplished by PPE including N95 mask, liquid-resistant long-sleeved gown, eye protection, and gloves.

Conclusion
PT plays a key role in the management of COVID-19 patients as early mobilization subsides the disease by improving their hemodynamic status and optimizing oxygen perfusion.Further, instructing patients in proper breathing and coughing techniques has a great impact on alleviating COVID-19 symptoms of cough, dyspnea, and hypersecretion.
In the future, hospitals may adopt tele-rehabilitation exercises via video platforms for conscious infectious patients.Furthermore, through meticulous documentation of rehabilitation processes and outcomes, valuable insights can be generated to refine management protocols effectively.This knowledge has the potential to enrich educational programs by providing real-world examples of patient management.The incorporation of comprehensive guidelines and educational strategies for physiotherapists can mitigate the effects of future epidemics and enhance the global prominence of physiotherapists in healthcare institutions.
Further research is warranted to determine the optimal timing for each exercise regimen and identify factors that trigger fatigue during sessions, along with strategies to alleviate such occurrences.

Fig. 1
Fig. 1 Physical therapy program.ROM, range of motion

Table 2
Presentation of case characteristics and PT management strategies

Table 2 (continued) Case Main patient problems Physical therapy objectives Comorbidities Physical therapy intervention Total session number LOS (days) Age (years) Gender Case severity on admission
RE respiratory exercises, ROM range of motion, CT computed tomography, RA room air, SOB shortness of breath, RSW right side weakness, BPH benign prostatic hyperplasia, UL upper limb, LL lower limb, NPMH no past medical history, AROM active range of motion, ICU intensive care unit, NRM non-rebreather mask, AF atrial fibrillation, HF heart failure devices (cane) and the SpO 2 was improved from 92% on nasal cannula of 10 L/m to 91% on RA without SOB.This case is of an 83-year-old male with a chest CT score of 4 and symptoms of dyspnea and SOB, along with a history of HTN, DM, and old stroke.Given that his SpO 2 was 96% on a simple mask at 3 L/min, he was admitted to the hospital.Upon admission, the patient received PT to maintain his general health and prevent further complications.
PT physical therapy, LOS length of stay, SpO 2 oxygen saturation, HTN hypertension, DM diabetes mellitus, BA bronchial asthma,