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      SARS CoV-2 (COVID-19): lessons to be learned by Brazilian Physical Therapists

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          Abstract

          The current severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) pandemic, also known as Coronavirus Disease 2019 (COVID-19), puts us at the forefront of scenarios with serious consequences for health systems in Brazil and in the world. 1 Current viral interstitial pneumonia has resulted in severe hypoxemic respiratory failure, which has resulted in overcrowding in intensive care units (ICUs), shortage of equipment and personnel, and significant mortality, especially in populations at risk who have chronic health conditions. 2 In most countries, the volume of patients has exceeded critical care capacities, with a shortage of personal protection equipment, multi-professional teams, and mechanical ventilators dominating the discussions in local hospitals and in the media.3, 4 While COVID-19 brought several challenges to the overall health care system, it also specifically highlighted the need for physical therapists to be properly trained and prepared to respond to such pandemic. First, it demonstrated the importance for every professional being updated, trained, and qualified in all technical skills related to infection control strategies such as wearing adequate professional clothing, effective hand washing, and use of personal protective equipment. Second, the importance of primary care in a good health care system. Patients with at least one comorbidity have higher odds of being hospitalized and being in ICUs. Also, individuals with chronic health conditions are more likely to develop a more severe form of the disease requiring ICU admission, mechanical ventilation, and more resources. Hypertension, cardiovascular diseases, hypercholesterolemia, and diabetes are the most common comorbidities in patients who died from COVID-19. 5 Consequently, the mortality rate (6.4%) of confirmed cases of COVID-19 in Brazil, within 52 days from the beginning of COVID-19 in every country, is around twice that of other countries, like Germany and Canada (3.0% and 4.1%, respectively), where the primary health care system is more effective in providing primary care.6, 7, 8 Thus, countries that have greater control over chronic health conditions may consequently have a lower mortality rate, with a population in better health being an important benefit in pandemic situations like the one we are witnessing with COVID-19. Third, the importance of the Cardiorespiratory and Intensivists (CRI) Physical Therapists in the Brazilian health system. CRI Physical Therapy is an established profession worldwide; however, the number of professionals in Brazil is much higher, and dozens of thousands work in hospitals. Interestingly, the ventilatory support and the improvement in musculoskeletal dysfunctions in ICUs are assisted by two professionals (Physical Therapists and Respiratory Therapists) in most countries; however, the CRI Physical Therapists are responsible for both in Brazil. The cumulative function reinforces the importance of the CRI Physical Therapists in the ICUs, as part of the multiprofessional team, minimizing the consequences of hospitalization and facilitating the recovery of patients. Ventilatory support in patients with COVID-19 includes several approaches: assistance in orotracheal intubation, support and management in mechanical ventilation, removal of airway secretion, changing patient's decubitus to improve gas exchange, and weaning patients from mechanical ventilation. 9 Additionally, these patients can present with consequences due to intensive care syndrome, including prolonged intubation, continuous sedation, and use of neuromuscular blocking agents that result in muscle weakness. 10 All these consequences from prolonged stay in the ICU are associated with an increase in morbidity and mortality. 11 Therefore, it is essential to start early rehabilitation in the ICU to promote rapid functional recovery. Some of these patients will present low exercise capacity, low physical activity level, increased sedentary behavior, dyspnea on exertion, and poorer quality of life after hospital discharge. CRI Physical Therapists will also be requested to help with the post hospital discharge rehabilitation program. Fourth and finally, this pandemic reinforces the importance for physical therapists to remain scientifically updated. The COVID-19 pandemic resulted in a significant increase in the number of studies reporting the impact of the disease 9 ; despite that, the pulmonary repercussion of the disease remains poorly known. 12 The difficulty in understanding how to offer optimal ventilatory support was the primary barrier for the CRI Physical Therapists. The previous professional experience was to administer ventilatory support for pneumonia based on the pathophysiology of Acute Respiratory Distress Syndrome (ARDS), where the severity of hypoxemia is associated with lung compliance. However, in COVID-19, CRI Physical Therapists faced, at least, two distinct phenotypes. Some patients present severe hypoxemia with respiratory system compliance remaining near normal, where hypoxemia seems to occur due to the loss of the hypoxic pulmonary vasoconstriction and impaired regulation of pulmonary blood flow. In another group of patients, severe hypoxemia is associated with lower compliance values, a condition similar to severe ARDS. 12 The difference between COVID-19 and ARDS required CRI Physical Therapists to be updated almost daily to understand how to give the proper ventilatory support. In conclusion, COVID-19 imposed a huge impact on the health care system in all countries, and everyone had to respond promptly in a very short time. Brazilian hospitals entire buildings and wards have been converted in semi-intensive and ICUs, and multidisciplinary teams, including CRI Physical Therapists, Physicians, and Nurses, have to receive special training for COVID-19. The Brazilian health system presents a special environment because it can count on the presence of CRI Physical Therapists as part of the ICUs multidisciplinary team. However, this is a unique moment in human history, and the countries that have adequately invested in research, the entire health care system, and hospital infrastructure are those that will suffer less in this war. Funding Conselho Nacional de Pesquisa (CNPq). Conflicts of interest The authors declare no conflicts of interest.

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          Most cited references 4

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          Is Open Access

          A Systematic Review of COVID-19 Epidemiology Based on Current Evidence

          As the novel coronavirus (SARS-CoV-2) continues to spread rapidly across the globe, we aimed to identify and summarize the existing evidence on epidemiological characteristics of SARS-CoV-2 and the effectiveness of control measures to inform policymakers and leaders in formulating management guidelines, and to provide directions for future research. We conducted a systematic review of the published literature and preprints on the coronavirus disease (COVID-19) outbreak following predefined eligibility criteria. Of 317 research articles generated from our initial search on PubMed and preprint archives on 21 February 2020, 41 met our inclusion criteria and were included in the review. Current evidence suggests that it takes about 3-7 days for the epidemic to double in size. Of 21 estimates for the basic reproduction number ranging from 1.9 to 6.5, 13 were between 2.0 and 3.0. The incubation period was estimated to be 4-6 days, whereas the serial interval was estimated to be 4-8 days. Though the true case fatality risk is yet unknown, current model-based estimates ranged from 0.3% to 1.4% for outside China. There is an urgent need for rigorous research focusing on the mitigation efforts to minimize the impact on society.
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            Physical activity, muscle strength, and exercise capacity 3 months after severe sepsis and septic shock

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              Digital physical therapy in the COVID-19 pandemic

              On March 11th/2020, the World Health Organization (WHO) declared Coronavirus Disease 2019 (COVID-19), a disease caused by the new coronavirus (severe acute respiratory syndrome coronavirus 2-SARS-COV-2), a pandemic. 1 In this global crisis, physical therapy all over the world, is being challenged to maintain its professional clinical activities in primary and secondary care in private clinics and public health systems.2, 3 Part of the challenge is to continue to provide necessary clinical care in a safe manner, for physical therapists, patients, and the community, by following the general recommendations of the WHO. 1 Social distancing and the interruption of physical therapy activities can have a tremendous negative impact on the health of thousands of patients. Digital physical therapy offers the possibility to continue providing some physical therapy services to patients, but regulations and implementation barriers are extremely heterogeneous around the world. The definition of digital physical therapy Before the COVID-19 crisis, in 2017 the World Confederation for Physical Therapy (WCPT) launched a collaboration to develop initiatives to the global practice and regulations of digital physical therapy practice through a Joint WCPT/INPTRA digital physical therapy Practice Task Force (Task Force). This report published in 2019 defined digital practice as “a term used to describe health care services, support, and information provided remotely via digital communication and devices”. The purpose of this initiative was “to facilitate effective delivery of physical therapy services by improving access to care and information and managing health care resources.” 4 However, for several physical therapists who have never had contact with this terminology, it is important to be aware that different terms are used in this field. There is still no global well-accepted term or definition for digital physical therapy among the literature industry, policymakers, and stakeholder groups. The variety of technologies that encompass this term may include tele-education, telemedicine, telemonitoring, teleassistance, mobile health, among others, and each field has its subset of technologies and specificities. The heterogeneity and barriers of digital physical therapy The worldwide COVID-19 pandemic forced the Brazilian health system to promptly adopt telehealth in different health care areas. The Federal Council of Physiotherapy and Occupational Therapy (COFFITO) allowed the use of telehealth, more specifically teleconsultation, teleconsulting and telemonitoring, for physical therapists (Resolution n° 516/March, 2020). 5 This change was promptly adopted to provide safe treatment delivery according to the WHO recommendations, however, no guidelines are available for physical therapists on how to use these technologies. Some countries currently use specifically designed and secure paid technologies to aid patient rehabilitation and monitoring. However, many physical therapists in Brazil and other similar countries are using free video conferencing software such as Google Hangouts, Zoom, and Skype although these tools were not designed to provide the necessary security in the sharing of health data. Other options include web-based platforms to create customized home-based exercise programs or augmented virtual reality platforms. The implementation of digital physical therapy should be done proactively rather than reactively to generate long term benefits to all parties involved. The COVID-19 crisis has been considered an opportunity for the advancement of telehealth in several countries. Australia, England, and the United States are facing several challenges, however, they included digital practice within the healthcare system a few years ago and recently their associations developed guidelines to assist professionals during the COVID-19 outbreak. The digital practice uptake was only possible because these countries already had the infrastructure needed to support these technologies. Countries like Brazil are just starting to discuss digital practice due to the recent regulation changes. There are several barriers related to digital practice implementation in a country that depend on different factors including infrastructure, legal and social issues, and economic aspects. The most important barriers are related to cost and reimbursement; legal liability, ethical issues such as confidentiality, outdated equipment, patient age and level of education; computer literacy, bandwidth range, and internet speed. 4 Opportunities and perspectives Digital physical therapy offers opportunities for users, service providers, and society, such as the expansion of access to health providers or specialists, encouragement of self-management, increase of flexibility for healthcare delivery, and decrease of sick-leave duration. Treatment efficacy and patient evaluation using digital practice were already investigated for some acute and chronic musculoskeletal conditions, cardiac conditions, neurological problems, post-surgical rehabilitation, pain management, pelvic floor conditions, and respiratory dysfunctions.6, 7, 8, 9, 10, 11, 12, 13, 14 The large-scale implementation of telehealth demands innovation in the technology market to improve capabilities and reduce cost to increase benefits. An important step for digital practice that will need support is data integration. As patients are remotely assessed or treated, professionals will need access to their relevant health data to provide the best care possible. That may be particularly challenging in a country where hospitals and clinics have different electronic health records systems or no electronic record system at all. Brazil as many other countries will need specific laws and guidelines on how to work with telehealth so that obligations and rights for all involved parties are clearly stipulated. Currently in Brazil, in the absence of specific guidelines and legislations, the safety of patients treated with telehealth is supported by resolutions of professional councils and laws about data protection on the internet such as law 13.709/2018 and its amendment 13.853/2019. 15 This law is known as the “General Law on Protection of Personal Data (LGPD)” and it reinforces concepts from the federal constitution in the online environment like free speech, privacy and honor protection, and access to personal information. The LGPD states that clients own their data meaning that individuals must know how their data are used and they can also require the deletion of all stored data from online service providers. The COVID-19 pandemic is stressing the capability of the health care systems across the globe, including the delivery of care for non-pandemic related health conditions. Digital practice will not be the solution for all the challenges that physical therapists will face; however, it is an exponentially growing field, widely adopted within the virus outbreak, and with the potential to reduce costs, increase quality, and overall accessibility of modern health care systems. The question now is whether physical therapists are prepared to implement digital practice to offer rehabilitation services during this undefined period of social distance due to the COVID-19. There is an unmet need to develop specific guidance on the many specific issues involving digital physical therapy practice. This task should involve each country's governmental authorities, physical therapy councils, and corresponding associations. Funding L.O. Dantas is a Ph.D. researcher from the São Paulo Research Foundation ( 10.13039/501100001807 FAPESP , Process number 2015/21422-6). Conflict of interest The author Barreto R.P.G is one of the owners of Vedius, a Brazilian company that has an online platform that enables health professionals to create and share home-exercise programs.
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                Author and article information

                Contributors
                Journal
                Braz J Phys Ther
                Braz J Phys Ther
                Brazilian Journal of Physical Therapy
                Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda.
                1413-3555
                1809-9246
                1 May 2020
                May-June 2020
                1 May 2020
                : 24
                : 3
                : 185-186
                Affiliations
                [a ]Department of Physical Therapy, School of Medicine, Universidade de São Paulo (USP), São Paulo, SP, Brazil
                [b ]Department of Physical Therapy, Universidade de Mogi das Cruzes, Mogi das Cruzes, SP, Brazil
                [c ]Department of Physical Therapy, Centro Universitário das Américas, São Paulo, SP, Brazil
                [d ]São Paulo Coordinator from the Associação Brasileira de Fisioterapia Cardiorrespiratória e Terapia Intensiva (Assobrafir), São Paulo, SP, Brazil
                Author notes
                [* ]Corresponding author at: Department of Physical Therapy, School of Medicine, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, CEP: 05360-000, São Paulo, SP, Brazil. cscarval@ 123456usp.br
                Article
                S1413-3555(20)30397-X
                10.1016/j.bjpt.2020.04.004
                7252009
                32387006
                © 2020 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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