Passive versus Active Ergometry in COVID-19 early rehabilitation: when is it safe to switch?
By: Mirjam Does – Exercise Physiologist at Lode B.V.
The International rehabilitation protocols and guidelines for Covid-19 patients are still (September 2020) under discussion. The standard rehab for lung diseases is not the correct guideline to follow since patients that have suffered heavily from the virus may have several comorbidities.
As been recently (July 2020) published as the Clinical Practice Guidelines (3): “Patients who are severely ill with COVID-19 who require hospitalization can present with complications such as pneumonia, hypoxemic respiratory failure/ARDS, sepsis and septic shock, cardiomyopathy and arrhythmia, acute kidney injury, and complications from prolonged hospitalization, including secondary bacterial infections. Because the consequences of the infection impact the respiratory system, one of the goals of physical therapist management is to optimize respiratory function. Therefore, respiratory support aims to improve breathing control, thoracic expansion, and mobilization/evacuation of secretion. Active mobilization aims to increase (or maintain) physical functioning and independence in activities of daily living (ADL). These recommendations also apply for patients recovering from critical illness due to COVID-19. Additionally, in patients recovering from critical illness respiratory muscle strength/endurance training can be continued”.
Passive or Assisted movement as such is by various experts (1, 2, 4, 6 and others) seen as a good way to start the early rehabilitation. Early rehabilitation is started in the ICU or critical care for the COVID patient as well like for instance the Johns Hopkins Expertise platform mentioned last April in the blog: “Recovery for Many COVID-19 Survivors Begins in the ICU” (9).
As soon as possible the switch is made to active movements (3, 7). COVID-19 patients however seem to response on early mobilization in ICU or critical Care with extreme heart rate and respiratory rate increments and SpO2 drops (3). For the physiotherapists and rehabilitation physicians it is important to receive clear guidelines for a save implementation of the passive and (the moment to switch to) active rehabilitation still supine in bed or in an upright position.
Typically passive ergometry (the patient does not apply force, the legs or arms are moved by a motor) is used for weak or even unconscious patients that do not have enough strength to operate a cycling movement themselves. As already published in 1996 by Koch et al (5) “Passive, active assisted, or active resisted limb movements are aimed at maintaining the range of motion of the joints, at improving soft-tissue length and muscle strength, and decreasing the risk of thrombo-embolism” .
Passive ergometry without active involvement is stimulating the range of motion of the joints and the blood circulation but is not improving the muscle strength and cardiopulmonary capacity of the patients.
Active ergometry (the patient applies force and rotates pedals with legs or handgrips with arms) is used for patients who have enough strength to move and need to be challenged to improve their general condition. Beside the positive effects of passive ergometry the extra advantages of the active ergometry are increasing muscle strength combined with the discontinuation of the muscle atrophy and improvement of the cardio-pulmonary capacity. Which will all contribute to increase physical functioning and independence in activities of daily living (ADL) (3,7)
Medical certified ergometers can also be used to accurately follow progress along standardized protocols. It is of course important to have the possibility to measure simultaneously the heart rate, oxygen saturation and blood pressure.
Covid-19 patients in need of rehabilitation have in most cases a long road to go. They may start with passive / assisted ergometry, while at a certain moment the switch to active ergometry needs to be made. Both can be done recumbent and/or upright. Critical parameters before starting active rehabilitation according the guideline (3) are the Heart rate (<110bpm), SpO2 (>90%) combined with the muscle force 3. During the active training the respiratory rate (still able to talk) and Borg scale (<4) are used together with the above.
A 0-watt start-up function to overcome the initial resistance of the ergometer and the possibility to start at an minimum workload of 7 Watt and make increments of only 1 watt are essential according to the experts (J. Sommers et al) I spoke in the Department of Rehabilitation, Amsterdam UMC, University of Amsterdam, the Netherlands. As an exercise physiologist I can imagine those rehab sessions need to be custom-made depending on the day by day status of the patient. At the same time it would be great when these custom-made session can be translated as much as possible to a standardized exercise protocol.
I would like to ask You, especially now the rehabilitation after the Covid-19 virus is becoming more important, what about your experiences and opinions. When is the time for you to switch from passive to the active ergometry? Do you have experience or ideas about an early rehab active bicycle ergometer protocol ?
For this, I would also like to point out the LinkedIn group: Covid-19 Rehabilitation Knowledge Sharing & Networking Group where the discussion and conversation are actively looked into.
By Mirjam Does MSc, Amsterdam, The Netherlands September 14th 2020.
1) Burtin C., Clerckx B., Robbeets C., Ferdinande P., Langer D., Troosters T., Hermans G., Decramer M., Gosselink R. (2009). Early exercise in critically ill patients enhances short-term functional recovery. Critical Care Medicine, 37(9), 2499-2505.
2) Clarissa C et al. (2019): Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities, in J of Intensive Care, 7, 1-19
3) Felten-Barentsz K.M., Oorsouw van R., Klooster E., Koenders N., Driehuis F.,Hulzebos E.H.J., Schaaf van der M., Hoogeboom T.J., Wees van der P.J. (July 2020). Recommendations for Hospital-Based Physical Therapists Managing Patients With COVID-19. Published by Oxford University Press on behalf of the American Physical Therapy Association
4) Kho M. E., Martin R. A., Toonstra A. L., Zanni J. M., Mantheiy E. C., Nelliot A., Needham D. M. (2015). Feasibility and safety of in-bed cycling for physical rehabilitation in the intensive care unit (ICU). Journal of Critical Care, 30(6), 1419.
5) Koch S.M., Fogarty S., Signorino C., Parmley L., Mehlhorn U.,(1996) Effect of passive range motion on intracranial pressure in neurosurgical patients. J Crit Care, 11 , pp. 176-179
6) Schaller S., Anstey M., Blobner M., Edrich T., Grabitz S., Gradwohl-Matis I., Heim M., Houle T., Kurth T., Latronico N., Lee J., Meyer M., Peponis T., Talmor D., Velmahos G., Waak K., Walz J., Zafonte R., Eikermann M. (2016). Early, goal-directed mobilization in the surgical intensive care unit: a randomised controlled trial. The Lancet, 388(10052), 1377-88.
7) Sommers J, Engelbert RH, Dettling-Ihnenfeldt D, et al. Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations. Clin Rehabil. 2015;29(11):1051-1063
8) Thomas P., Baldwin C., Bissett B., Bode J., Gosselink R., Granger C.L., Hodgson C., Jones A.Y.M., Kho M.E., Moses R., Ntoumenopoulos G., Parry S.M., Patman S., Lee van der L., (2020). Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. Journal of Physiotherapy 66 (2020) 73–82