Coronavirus (COVID-19) Rehabilitation Guide | Hull University Teaching Hospitals NHS Trust

Reference Number: HEY1195/2020
Departments: Coronavirus - COVID-19, Physiotherapy
Last Updated: 22 December 2020

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This leaflet has been produced to give you general information. Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and the healthcare team, but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is Coronavirus (COVID-19)?

Coronavirus (COVID-19) is an infectious virus that mainly affects the lungs. Breathlessness at rest and during activities is a normal symptom of Coronavirus (COVID-19). All staff treating you will be wearing protective equipment, and during some treatments you may be asked to wear a mask to minimise the risk of spreading the virus.

Breathlessness and Managing Breathlessness

Why do I feel breathless?

Breathlessness is a very common symptom in some people with Coronavirus (COVID-19). The lungs can become inflamed and the effort of breathing can increase. You may be breathing quicker and shallower, however it is important to try and stay calm. Anxiety can increase your heart rate and make your breathing rate increase further.

Breathing control – aids relaxation

Get in a comfortable position
Close your eyes and bring attention to your breath
Breathe in and out through your nose (or mouth if you are unable to do this)
Notice areas of tension in the body and try to release this with each breath out
Gradually try and make your breaths slower and deeper

Pursed lip breathing – useful during activities that make you feel breathless

Breathe in gently through your nose
Breathe out with your lips pursed as if you are whistling
Try to blow out as long as comfortable (do not force your lungs to empty)

Blow as you go – useful during activities that make you feel breathless e.g. lifting an object

Breathe in before you make the effort
Breathe out whilst making the effort (e.g. whilst object lifted)
Always breathe out at the most difficult part of the action

Active cycle of breathing technique – repeat the cycle 2-3 times to help clear secretions

3 to 4 breaths
Then normal breathing
Then 3 to 4 breaths
Then normal breathing
Then huff
Repeat

Why might I need supplementary oxygen?

You may have been prescribed medical oxygen (through a mask or nasal prongs) to help improve oxygen levels in the body. This will regularly be assessed and may be prescribed when you go home.

Positions of ease – may help to reduce breathlessness and effort of breathing

High side lying

Lie on your side
Use multiple pillows under your head and shoulders
Bend your knees a little

Supported forward sitting

Sitting upright, lean forward on to a table
Add as many pillows as required

Forward sitting

Sit leaning forward
Rest your forearms on your knees
Relax your chest and shoulders

Supported standing

Stand leaning forward and use a chair, bench or wall for support
Relax your chest and shoulders

Postural Changes – can help to move sputum and promote deep breathing

Lying on your stomach

Lie on your abdomen (front)
Turn your head to one side
Use a pillow to support your head

Sitting up in bed

Raise the bed between 45 and 60 degrees
Use a pillow to support your neck

Side Lying

Lie on your side
Use a pillow to support your neck
Bend your knees a little

Left side lying

Lie on your abdomen (front)
Turn your head to the left
Bend the left leg and left arm up
Keep your right arm behind you
Use a pillow to support your head

Why is Mobility and Exercise important?

Movement will help your breathing, help to clear sputum and improve your exercise tolerance, muscle strength and mental health. It may help you to be discharged earlier. Our treatment will focus on breathing, functional and physical exercises.

What can I do?

Get up at a normal hour
Complete morning tasks e.g. get washed, brush teeth, get dressed
Sit out in the chair for meals
Fill in an exercise diary
Open the blinds / curtains at windows during the day

Please note:
If you are not under the care of a therapist you may undertake these exercises at your own risk. Only undertake exercises that are within your capabilities. Ensure you consult your with doctor before completing anything if you have previously been advised against certain exercises due to pre-existing health conditions.

Exercises

Please note:
Only complete exercises that have have been discussed with you, and ticked in this checklist by the therapists. This applies to when you are at the hospital, and at home.

Therapist exercise checklist with images – page 1
Therapist exercise checklist with images – page 2

Exercises include:

Walk
Cycle
Step
Seated walk
Ankle raises
Ankle rotations
Knee bends
Lying leg raises
Lying side leg raises
Bridge
Seated leg raise
Single leg balance
Calf raises
Sit to stand
Squat
Weighted squat
Shoulder roll
Arm raises
Bicep curl
Shoulder press
Chest press (lay on bed)
Lateral raise
Tricep extension
Upright row

Other than the cycling, you do not need any special equipment to do these exercises. Calf raises can be done over the edge of a step or stair, and you can use bottles of water, bags of fruit or vegetables or tins of food as hand weights. If your exercises have become too easy, you could increase the number of minutes that you hold the weight or stretch , or the number of times you repeat the exercises (repetitions/ reps) before having a rest, or the number of sets of each exercise. To be effective, your exercises should feel somewhat hard (i.e. you are aware that your heart rate has increased, you are breathing more deeply and you may feel warm, but you should still be able to talk to someone whilst you are exercising).

Warning:

If you feel unwell during exercise then stop and inform the ward staff if you are in hospital.
If you are at home, stop and inform the doctor or team that are reviewing you.

Fatigue Management

You may be wondering why your energy levels are low and why performing simple activities of daily living suddenly feel like a marathon. Although rest is important in recovery, unlike normal tiredness it does not improve with rest alone. If you are experiencing Coronavirus (COVID-19) related fatigue you may feel unwell and exhausted after the infection has passed.
This fatigue can also be affected by other factors such as:

Shortness of breath caused from the Coronavirus (COVID-19) infection of the lungs
Muscle deconditioning from having spent long periods inactive and in bed
Stress you may feel after going through a period of serious ill health

Physically you may feel weak and drained as you try to do activities. It may affect your thinking skills meaning you may struggle to concentrate for long periods, or process lots of information at once. It can affect your emotions so you may feel more frustrated, tearful and anxious.

What can I do about fatigue?

Fatigue can make managing your usual daily tasks more difficult. All daily tasks require the body to use energy through moving and thinking. Fatigue management can help you to understand how to make the most of your body’s available energy. This can help you to find ways to balance your physical, social and emotional needs when your energy levels are reduced.

Completing a fatigue diary and rating your fatigue before and after an activity (e.g. having a wash and getting dressed) can help you to understand how different activities can affect your energy levels. Rating your fatigue from 1 – 10 will help you identify patterns of fatigue. This may help you to identify strategies to manage your fatigue e.g. taking a rest in sitting during an activity, or conserve your energy for the important activities that you value.

How to use a fatigue diary:

Start at the beginning of each day
Write down each activity and rest period you have taken in each 2 hour box
Using the scale score – where ‘0’ is no fatigue and ‘10’ is worst fatigue imaginable – how you felt at the end of this 2 hour period
Record any other factors you feel are relevant e.g. stressful events, skipping meals, over-exertion

Nutrition and Hydration

Adequate nutrition and hydration play an important role in your body’s response to fight and recover from Coronavirus (COVID-19). Eating well (together with the exercises) will help to rebuild your muscle strength and function. Even though you may not feel hungry or thirsty, it is important to eat and drink well.

Below is some general information to help you to optimise your food and fluid intake. If you have specific dietary requirements, please check with a healthcare professional that the information is safe for you to follow.

Stay hydrated

Drink regularly throughout the day – take small, frequent sips of liquids every few minutes if you are not able to drink large volumes at one time
Aim to drink enough fluid to keep your urine a pale straw colour
If you have a raised temperature, your fluid needs may be higher
All fluids (except alcohol) count, try to include nourishing fluids such as milky drinks or juices

Take in enough calories and protein to be well nourished

You may require more nutrition than usual to support your body during, and after, illness. Restriction of energy intake with the aim of reducing body weight is not appropriate during acute illness or recovery due to the risk of reducing lean body mass, strength and function.

Include a protein-containing food and / or drink at every meal e.g. milk, milk-based food (or alternatives if unable to have dairy), meat, fish, beans, eggs
If your appetite is poor and/or eating is difficult due to breathlessness, aim to have 3 small meals and 3 high protein / energy snacks per day
You may be prescribed ‘supplement drinks’. These provide extra energy, protein, vitamins and minerals. They should be taken in addition to (not instead of) meals. Try sipping them after your meals so they do not fill you up for your mealtimes.

Swallowing, Mouth Care and Voice

Swallowing

Some individuals may experience difficulties with their eating and drinking after being admitted to hospital with Coronavirus (COVID-19).

If you are experiencing any indicators of swallowing difficulties listed below speak to your doctor.

Coughing / choking when eating and drinking
Feeling as though food is getting stuck
Gurgly / wet voice
Poor appetite
Recurrent chest infections
Throat clearing when eating and drinking
Weight loss

Mouth Care

It is really important that you keep your mouth clean and moist. Oxygen masks can dry your lips and mouth out; ensuring good mouth care can prevent soreness/ infection:

Brush your teeth twice daily with toothbrush and toothpaste
Take regular sips of water

Voice

You may have experienced changes to your voice since being in hospital with Coronavirus (COVID-19). There may be several reasons for this, including: the insertion of a breathing tube; a persistent cough; dehydration of your voice box; acid reflux; fatigue and stress. You may experience one of more of the following symptoms:

Croaky or husky voice
Difficulty projecting the voice
Increased throat mucus or throat clearing
Sore or dry throat
Weak, breathy voice

The inflammation and damage to your voice box should get better without treatment over the next few weeks however if it does not, ask for a referral to the Ear, Nose and Throat department via your doctor.

Thinking and Communication

Some individuals may experience difficulties with their thinking. This can impact on the way that they communicate with other people. You may experience one of more of the following difficulties:

Having a conversation
Putting your thoughts and feelings into words
Reading
Understanding what people are saying

If you are experiencing any of these difficulties, ask your doctor to refer you to Speech and Language Therapist.

Psychological Health

Going through intensive or high dependency care can be physically and psychologically difficult. You may have little or no memory of the events leading up to your admission or time on intensive care which can leave you feeling confused. Waking up after being sedated, surrounded by staff in protective equipment may leave you feeling anxious and frightened. You may have to re-learn to do things that you once could do very easily e.g. walking.

You may experience some of the following difficulties:

Anxiety
Changes to sight, hearing, taste or smell
Depression
Fatigue
Memory loss
Pain
Post-traumatic stress symptoms (hallucinations/nightmares/fear/anger)
Sleep problems
Social problems

Understanding Anxiety

Thinking about events from intensive care or worrying about the future, can release adrenaline in the body which activates the body’s ‘fight or flight’ response. When adrenaline is not being used for ‘fight or flight’, you may experience unpleasant mental and physical sensations (which cannot physically harm you) such as:

Feeling hot with clammy hands – blood moving to your muscles
Increased breathing rate – this can make you feel dizzy or faint
Increased heart rate – a pounding or racing in your chest
Racing thoughts – unable to relax and sleeping difficulties
Sinking feeling in the stomach – blood is being diverted from your digestive system to your muscles

Family can also experience anxiety as they come to terms with what you have been through. Both you and your family may benefit from doing some relaxation. The STOP exercise below might be helpful:

Stop

Whatever you are doing, just pause momentarily.

Take a breath.

Re-connect with the breath. The breath is an anchor to the present moment.

Observe

Observe your experience just as it is – including thoughts, feelings and emotions

What is happening inside and outside of you? Notice your body.
Are you standing or sitting? How is your posture? Any pain?

You can reflect about what is on your mind and also notice that thoughts are not facts, and they are not permanent.

Notice any emotions present and how they’re being expressed in the body.
Research shows that just naming your emotions can turn the volume down on the fear circuit in the brain and have a calming effect.

Proceed

Continue doing what you were doing, or use the information gained during this exercise to change course.

Proceed with something that will support you in the moment;
e.g. talk to a friend, rub your shoulders, have a cup of tea

Whatever you do, do it mindfully.

What will happen when I am discharged?

When it is time for you to be discharged from hospital the team who have been looking after you will discuss the support and follow up you will receive when you go home.

If your health deteriorates at any time please contact your doctor or 111 for help and advice

Understanding Post-traumatic Stress

After being very unwell in hospital, it can take time for our brain to process this experience. It is normal to have vivid and frightening hallucinations and nightmares which should subside over days or weeks. If you are struggling to manage or if you find that they continue for a prolonged period, speak with your GP for guidance.

What can you do?