Oxygen Therapy During Activities of Daily Living Rehabilitation and Outcome in Patients With Severe-to-critical COVID-19.

Objective: To primarily study the duration of supplemental oxygen use while performing ADLs (activities of daily living) and associations leading to a more prolonged oxygen therapy during these tasks. Secondary objectives include (1) studying the presence of COVID-19 related complications during inpatient rehabilitation and after discharge and (2) describing functional outcomes of participants after supplemental oxygen liberation and hospital discharge. Design: Explorative prospective observational cohort study. Setting: Rehabilitation center within a tertiary hospital, caring for post-COVID patients. Participants: Twenty-three (N=23) community-dwelling persons with severe-to-critical COVID-19 disease and ongoing oxygen therapy needs. There was a preponderance of men (69.6%), with mean age of 69.5 (range 46-85) years. Interventions: Inpatient pulmonary rehabilitation. Main Outcome Measures: The primary outcome was the duration of supplemental oxygen use (from initiation till wean) for ambulation, toileting, dressing, and showering. Secondary outcomes included the presence of COVID-19 related complications (during rehabilitation and after discharge) and post-discharge functional status. Results: After rehabilitation center transfer, all subjects only required oxygen therapy during task(s) performance, and not at rest. ADLs that took the shortest and longest time for supplemental oxygen weaning were dressing (mean 38.4±SD 17.1 days) and showering (mean 47.7±SD 18.1 days), respectively. The mean duration of oxygen therapy application was 48.6±SD 18.3 days. On multivariable analysis, mechanical ventilation and exertional desaturation were significantly associated with prolonged duration for oxygen therapy in all ADLs. Conclusion: The duration of needful oxygen therapy was dissimilar for different ADLs. Showering, which required the longest duration of supplemental oxygen wean, might prove to be the rate-limiting ADL for discharge home.

Changes in muscle architecture on ultrasound in patients early after stroke.

BACKGROUND: Early muscle changes are believed to occur in patients with stroke. However, there are insufficient data on the changes in muscle mass and architecture of these patients. OBJECTIVES: This study investigates differences in ultrasound-derived muscle architecture parameters of the hemiplegic upper and lower limbs in patients with subacute stroke. METHODS: This is a prospective observational study, which recruited 40 adult patients who had experienced a first ever unilateral stroke (ischemic or hemorrhagic), with a duration of < 1 month post stroke. The brachialis, vastus lateralis and medial gastrocnemius on both the hemiplegic and normal side were evaluated via ultrasound. We recorded clinical variables including Motricity Index, Modified Ashworth Scale (MAS) and Functional Independence Measure (FIM)-walk. RESULTS: We found reduced mean muscle thickness (p < 0.001) and increased echo intensity (p < 0.001) in the brachialis muscle, increased echo intensity (p = 0.002) in the vastus lateralis muscle, and reduced muscle thickness (p < 0.001) with increased echo intensity (p < 0.001) in the medial gastrocnemius muscle compared to the normal side. There were no significant correlations between ultrasound findings and Motricity Index. CONCLUSIONS: We report changes in ultrasound-derived muscle architecture in the hemiplegic limbs of patients with subacute stroke, with consistent findings of decreased muscle mass and increased echo intensity.

Singapore multidisciplinary consensus recommendations on muscle health in older adults: assessment and multimodal targeted intervention across the continuum of care.

BACKGROUND: The rapidly aging societies worldwide and in Singapore present a unique challenge, requiring an integrated multidisciplinary approach to address high-value targets such as muscle health. We propose pragmatic evidence-based multidisciplinary consensus recommendations for the assessment and multi-modal management of muscle health in older adults (≥65 years) across the continuum of care. METHODS: The recommendations are derived from an in-depth review of published literature by a multidisciplinary working group with clinical experience in the care of the older population in both acute and community settings. RESULTS: The panel recommends screening for muscle impairment using the SARC-F questionnaire, followed by assessment for low muscle strength (handgrip strength or 5-times chair stand test ≥10 s as a surrogate for lower limb strength) to diagnose possible/probable sarcopenia. For uncomplicated cases, lifestyle modifications in exercise and diet can be initiated in the community setting without further assessment. Where indicated, individuals diagnosed with possible/probable sarcopenia should undergo further assessment. Diagnosis of sarcopenia should be based on low muscle strength and low muscle mass (bioimpedance analysis, dual-energy X-ray absorptiometry or calf circumference as a surrogate). The severity of sarcopenia should be determined by assessment of physical performance (gait speed or 5-times chair stand test ≥12 s as a surrogate for gait speed). To treat sarcopenia, we recommend a combination of progressive resistance-based exercise training and optimization of nutritional intake (energy, protein and functional ingredients). High quality protein in sufficient quantity, to overcome anabolic resistance in older adults, and distributed throughout the day to enable maximum muscle protein synthesis, is essential. The addition of resistance-based exercise training is synergistic in improving the sensitivity of muscle protein synthesis response to the provision of amino acids and reducing anabolic resistance. An expected dose-response relationship between the intensity of resistance-based training, lean mass and muscle strength is described. CONCLUSIONS: Reviewed and endorsed by the Society of Rehabilitation Medicine Singapore and the Singapore Nutrition and Dietetics Association, these multidisciplinary consensus recommendations can provide guidance in the formulation of comprehensive and pragmatic management plans to improve muscle health in older adults in Singapore and Asia.

Rehabilitation of Patients with Platypnea-Orthodeoxia Syndrome in COVID-19 Pneumonia: Two Case Reports.

Platypnea-orthodeoxia syndrome, characterized by dyspnoea and arterial desaturation while upright, is a rare complication of acute respiratory distress syndrome. We report here 2 patients with COVID-19 pneumonia, who were diagnosed with platypnea-orthodeoxia syndrome during commencement of rehabilitation, 18 and 9 days respectively after admission to the intensive care unit. Both patients presented with normocapnic hypoxaemia. One patient required mechanical ventilation with supplemental oxygen during intensive care, while the other required high-flow nasal oxygen therapy. The manifestations of platypnea-orthodeoxia syndrome were most prominent during physiotherapy, when verticalization was attempted, and hindered further mobilization out of bed, including ambulation. This report describes the clinical manifestations of platypnea-orthodeoxia syndrome and the rehabilitative strategies carried out for these 2 patients. The platypnea-orthodeoxia syndrome in these patients resolved after 65 and 22 days respectively from the day of detection. This report highlights this potentially under-recognized phenomenon, which may be unmasked during rehabilitation of patients with COVID-19 pneumonia. Good functional outcomes were achieved with a combination of verticalization training with supplemental oxygen support, respiratory techniques training and progressive endurance and resistance training, whilst awaiting resolution of the platypneaorthodeoxia syndrome.

Acute Functional Outcomes in Critically Ill COVID-19 Patients.

Background: COVID-19 (Coronavirus Disease 2019) is a global cause of morbidity and mortality currently. We aim to describe the acute functional outcomes of critically ill coronavirus disease 2019 (COVID-19) patients after transferring out of the intensive care unit (ICU). Methods: 51 consecutive critically ill COVID-19 patients at a national designated center for COVID-19 were included in this exploratory, retrospective observational cohort study from January 1 to May 31, 2020. Demographic and clinical data were collected and analyzed. Functional outcomes were measured primarily with the Functional Ambulation Category (FAC), and divided into 2 categories: dependent ambulators (FAC 0-3) and independent ambulators (FAC 4-5). Multivariate analysis was performed to determine associations. Results: Many patients were dependent ambulators (47.1%) upon transferring out of ICU, although 92.2% regained independent ambulation at discharge. On multivariate analysis, we found that a Charlson Comorbidity Index of 1 or more (odds ratio 14.02, 95% CI 1.15-171.28, P = 0.039) and a longer length of ICU stay (odds ratio 1.50, 95% CI 1.04-2.16, P = 0.029) were associated with dependent ambulation upon discharge from ICU. Conclusions: Critically ill COVID-19 survivors have a high level of impairment following discharge from ICU. Such patients should be screened for impairment and managed appropriately by rehabilitation professionals, so as to achieve good functional outcomes on discharge.

A case of anti-NMDAR (N-methyl-D-aspartate receptor) encephalitis: a rehabilitation perspective.

Anti-NMDAR (N-Methyl-D-Aspartate Receptor) Encephalitis is a rare occurring autoimmune disease that is mediated by antibodies against the NR1 subunit of the NMDA receptor. While this condition has a known predilection for young females with ovarian tumors, heightened awareness has led to increasing recognition of this condition in other population groups as well. Afflicted patients typically evolve through a multi-staged course of neurological, behavioral, cognitive and physical deficits. The diverse nature of this condition often necessitates a multi-disciplinary team for management. As the recovery of patients with anti-NMDAR encephalitis is often protracted, the role of the rehabilitation is important particularly beyond its acute stages. We describe a case of anti-NMDAR encephalitis in a 17-year-old girl who presented to our rehabilitation centre for management in the gradual recovery phase of her condition. This case illustrates the multiple challenges faced in the rehabilitation of such a patient.