In late 2019, the outbreak of a respiratory disease caused by a human coronavirus (SARS CoV-2) was discovered in Wuhan, China. The infection spread globally and in March 2020 was recognized as a pandemic by World Health Organization (WHO) and the disease was given the name COVID-19.  Since the onset, researchers and health professionals have been working on providing information on the varying clinical course of this disease.

COVID-19 primarily affects the lungs with presentation of ARDS (acute respiratory distress syndrome) and subsequent fibrosis. It appears to have a systemic inflammatory response with multiple organ involvement. Presentation of those affected by the virus varies greatly from asymptomatic to severe complications requiring mechanical ventilation support. Those who are physically fit and leading a healthy lifestyle are comparatively less affected than those who have pre-existing conditions.

       Considerations post infection:

• Post viral fatigue syndrome, is characterized by early fatigue, sleep disturbances, early breathlessness, aches and pains and lethargy. In such cases, relaxation techniques and activity pacing is recommended, along with adequate nutrition. Vitals such as blood pressure, heart rate and oxygen levels may be monitored and consultation with a physician is required if vitals fluctuate often.
• Critical illness myopathy / ICU acquired weakness– physical deconditioning and diffuse muscle weakness due to long ICU stay. Rehabilitative programs can be effective to reverse muscle weakness and health systems should provide required facilities.
• Psychological and cognitive effects– confusion, anxiety, depression psychosis.

Recovering from this disease can be challenging, especially for those who are symptomatic, as symptoms still persist, making it difficult to cope with everyday life. Hence pulmonary rehabilitation is vital so that patients are systematically guided to get back to pre COVID life. Pulmonary Rehabilitation is a comprehensive intervention based on a  thorough patient assessment followed by patient tailored therapies that include, but are not limited to, exercise training, education and behavior change, designed to improve the physical condition of people with respiratory diseases. (American Thoracic Society)

Recommendation for Physiotherapeutic Interventions

• Physiotherapeutic maneuvers include body positioning to improve ventilation perfusion ratio and oxygenation, airway clearance to clear secretions in the airway and early mobilization to combat ill effects of deconditioning and prevent critical illness myopathy and improve function and quality of life.
• For asymptomatic patients and those with mild symptoms, therapy can be provided through Telerehabilitation. Advice on the following can be given:

1. Early mobilization
2. Low to moderate intensity exercises depending on individual capabilities
3. Breathing control exercises
4. Deep breathing exercises for impaired lung function
5. Respiratory muscle strengthening and conditioning
6. Limb mobility exercises
7. Limb strengthening and endurance
8. Cognitive functions and mental health support
9. Psychological and nutritional counseling

(Note: Keep a check on vitals, especially those with pre-existing conditions and maintain an activity log. Activity pacing and self symptom monitoring must be incorporated

Caution: no active exercises if fever and weakness are worsening).

Below are a few techniques of breathing exercises that can be performed, which will keep your lungs well ventilated, improve oxygenation in your body, clear secretions if present and induce relaxation.

• Pursed Lip Breathing– Sit in a relaxed position and take a deep breath through your nose, hold for 1-2 seconds and then breathe out through your mouth with pursed lips. On breathing in, the chest will expand; on breathing out, the chest will return to normal (10-15 counts, twice a day)
• Diaphragmatic Breathing Exercise– Shoulders relaxed, lean back a little bit, place your hands on your abdomen. Take a deep breath through your nose and feel your tummy filling with air, and then breathe out through your mouth with pursed lips. 10-15 counts, twice a day
• Chest Expansion exercise– Place your hands on your upper chest in a cross fashion, such that your hands reach your shoulders, take a deep breath in, and feel the expansion of your upper chest, and breathe out through your mouth with pursed lips. 10-15 counts, twice a day
• Breath Stacking technique: Take a small breath, hold for 1-2 seconds, without breathing out, take another breath, hold for 1-2 seconds, if possible take the third small breath and hold for 1-2 seconds and then breathe out through your mouth with pursed lips. Basically stacking your breath and then releasing it at once.

(Note: keep a check for any abnormal symptoms like chest pain, palpitations, dizziness and breathlessness during the exercises, and if needed, consult with your therapist regarding the same).

Kimberly Dias