And that's just for y'all to have for your record and stuff, for the recording. All right, let's get rocking. So everyone welcome to the August edition of the AAP Medical Student Council Journal Club. Today we're covering a super awesome topic, COVID-19. It's been a part of our lives for the past couple years or so now, much more than we thought we'd like it to be, but makes an important part in the rehabilitation side of things now with all the patients coming through needing rehabilitation for this type of disease. So got a lot of cool speakers out there tonight. We got Kirk Shipley, Kristen Beccaro, and Nimisha Mehta, and then of course Dr. Sam Mayer, who's our vice chair out of the department of PM&R at Johns Hopkins Medical Center. So let's go ahead and get started. So first up we have Kirk, who's our fourth year med student at the American University of Caribbean, talking about clinical manifestation, evaluation, and rehabilitative strategy of dysphagia associated with COVID-19. Okay. Good evening, everyone. So today, my article that I'll be presenting is a clinical manifestation evaluation and rehab strategy of dysphagia associated with COVID-19. So I got this article from the Journal of Physical Medicine and Rehab in the May 2021 issue. So my objective today is to go over the background and introduce the study, talk about the pathophysiology of COVID-19 dysphagia, review the dysphagia evaluation and rehab management, and go over some conclusions and future directions. So my article is a literature review, and the purpose was to present modified recommendations for dysphagia evaluation management for COVID-19 patients that allow a safe, comprehensive, and practical encounter based on available evidence today. So dysphagia has been a recent COVID-19 complication report in the literature. This is both due to peripheral and central nervous system pathology. I'll explain each of these in the next few slides. It can also be caused by disuse syndrome, sarcopenia, and prolonged endotracheal intubation. And this is important because untreated dysphagia contributes to the high morbidity and mortality rate of the disease due to things like pulmonary complications, aspiration pneumonia, to name a few. So dysphagia rehab under the COVID-19 umbrella has been challenging due to infection control matters. Interpersonal rehab therapy has been delayed or minimized. And this has caused a steeper physical decline, this amuse atrophy in poor patient outcomes. And the gold standards of dysphagia evaluation, the FEES and the VFSS have also been delayed or minimized due to the fact that these are aerosol generating procedures. And since COVID-19 is transmitted through respiratory droplets, this has deemed unsafe. So the evaluation and rehab management of dysphagia have to be modified as the situation demands. So next I'll go over a little bit about the pathophys, about dysphagia in COVID-19 patients. So COVID-19 is a respiratory disease, but also affects many of the other systems of the body, including the neurological and cardiovascular system. A study by Mayo et al. reported that one third of hospitalized patients in this study displayed some sort of neurological signs or symptoms. And there's two mechanisms for this, hematogenous or transneuronal, and this is responsible for the hypogeusia and hyposmia, the two common symptoms of COVID-19, so the loss of taste and smell. And the other mechanism is the abnormal immune-mediated response. And this is responsible for the autoimmune diseases that COVID-19 can cause, as well as cytokine overproduction. So here's a slide that basically demonstrates that swallowing is a dynamic process involving both the central, so up here on top, including the cortex and brainstem, and the peripheral nervous system, so the cranial nerves. And these things on the slide are the complications that COVID-19 can cause, and I'll talk a little bit about each of these as well. So here's a list of the cranial nerves involved in swallowing, and the two important ones are the glossopharyngeal and the vagus nerve. The glossopharyngeal has motor innervations of the solid pharyngeus, which helps elevate the pharynx and larynx, and the vagus provides sensation to the pharynx, larynx, and trachea, as well as the pharyngeal constrictors and intrinsic muscles of the larynx. So the first complication of COVID-19 that causes dysphagia is peripheral neuropathy, and this is most commonly seen in the olfactory nerve, presented as hyposmia and hypoguesia. So a cross-sectional study by Nucci et al. showed that one-third of patients presented with these symptoms, and it's interesting because in this study, he saw the outpatient patients in the outpatient setting present with these two symptoms more than the inpatient setting. So peripheral neuropathy can also affect the glossopharyngeal and vagal nerves, and to demonstrate this, the study reported a case report about a patient that was taken off a ventilator that started developing dysphagia, and aspiration pneumonia was diagnosed. The patient had bilateral gag reflex, which was absent, so the patient undergoed some studies, including the FES and the VFSS, which showed impaired pharyngeal, laryngeal sensation, and mesopharyngeal contractile dysfunction, showing that the cause of the dysphagia was peripheral neuropathy to both these nerves. A second cause of dysphagia in COVID-19 patients is autoimmune. So the most common reported autoimmune association with COVID is the Gilligan-Bearer syndrome, or GBS. So Gilligan-Bearer syndrome is common, or the most common cause of GBS are viral diseases, and a systematic review by Abirumilea found that there were 73 published cases, and this study was done in 2020, so I'm sure there's been more reported cases of COVID-19 association with GBS. So past coronaviruses have been associated with GBS, and a recent report by Northern Italy revealed that 20 percent developed dysphagia. So dysphagia in GBS is also not an uncommon finding. So GBS can affect the legs first, but in 10 to 30 percent of patients also affect the respiratory syndrome, and in one report, about 40 percent of patients had effects in the cranial nerves in later stages of the disease. So some other autoimmune diseases that COVID-19 can cause include encephalitis, encephalomyelitis, and myositis, and a brain study in six patients in Germany showed some sort of encephalitis, axon degeneration, and hypoxia alterations in all six brains. The last pathology that causes dysphagia in COVID-19 patients is CVA. So the increased hypercoagulable state in COVID-19 causes the CVAs. There's two hypotheses. One is a severe high inflammatory response, and some studies show the direct activation of the coagulation cascaded by the virus itself. In a retrospective study in two New York hospitals showed that 1.6 of COVID-19 patients developed some sort of ischemic stroke, and the study compared this to other viral illnesses, and the influenza virus in comparison only had about 0.2 patients with COVID that developed some sort of ischemic stroke. So here's another study, a surveillance study of 125 patients in three major UK neuroscience centers, and basically this study presented with the most common neurological complications in these three hospitals, and 62 percent of the most common neurological consequence was a CVA event. So other causes of COVID-19 that causes dysphagia is malnutrition, sarcopenia, and prolonged mechanical ventilation. Next I'm going to be talking a little bit about the dysphagia evaluation and management. So patients with COVID-19, especially patients that have been intubated, should all be screened for dysphagia, and the screening initially starts with three simple screening tests. The water swallowing test, which another name is the Yale swallow test, the patient basically swallows three ounces of water, and if the patient can swallow the water without any regurgitation, any coughing, this is considered a successful test. A repetitive saliva swallowing test is another screening option, and a questionnaire such as the EAT-10. So the instrumental evaluation is the next step. So like I mentioned, the FEES and the VFSS are the gold standards for the evaluation. So the FEES is basically you put a scope and visualize the pharynx, and the VFSS is also known as a modified barium swallow test, and this is a real-time using fluoroscopy, and the patient will swallow some barium-coated liquid or semisolids. So basically, here's a picture of the FEES. So like I mentioned, it's a scope looking at the pharynx and the VFSS. So it's under fluoroscopy, and you can see the patient's swallowing a barium-coated liquid or solid. So the rehab strategy of dysphagia can be divided into restorative, which is the exercises, and the compensatory, which include posture, diet, swallowing, maneuvers, and surgery. So studies have shown that early treatment of dysphagia have been shown to reduce the patient's risk for aspiration pneumonia, reduce medical complications, and reduce the length of the hospital stay, and actually improve the outcomes of these patients. So unfortunately, COVID-19 has postponed the management and treatment of these patients, which have resulted in poorer outcomes for these patients. The first restorative is exercise training. So these utilize overloading and specificity. Specificity basically means that you want to use exercises that target behavior, or sorry, that are most similar to the target behavior. So the Mendelson and the Misako are two examples. Mendelson, you intentionally hold the larynx up when the larynx is elevated, and that strengthens the super hard muscle. And then overloading basically means you want to do these exercises at a resistance level higher than you would typically use. And down here is just a list of some exercises that uses overloading. So the oropharyngeal system exhibits plasticity considerations, and it's considered a very plastic system. So to target this, for management, you can use something called an electrical stimulation. So you can either use a peripheral or central, and this has shown to increase pharyngeal and esophageal motor cortical expansion. So here's a picture that shows both the peripheral, so it targets the pharynx right here, and then the central, so you can put some electrodes that targets the cortex and subcortex. So for maneuvers, they're to be formed with every swallower just before a meal. So some common ones include self-dilation of the upper esophageal sphincter, and this is accomplished by the patient inserting a balloon catheter into the upper esophageal sphincter. Then also thermal tactile stimulation. So a chilled laryngeal mirror strokes the anterior pillars five to six times before and after during a meal. The next common story strategy is posturing. So this is reported to be successful in 80% of all swallowing disorders. Basically, it uses gravity and temporary changes in anatomy to help the patient swallow. So here's a list of some common postural strategies. Due to the length of time, I'm going to move on. Diet. So you can help modify the food and liquid properties and presentation, and it's interesting because studies have shown that taste and chemesthesis actually help patients with swallowing. So patients can eat something spicy or sour, such as chili peppers, and it actually helps the patient swallow. So next, we're going to talk about COVID-19 complications, or sorry, the implications of COVID-19 with dysphagia. The recent articles recommended the initial interview, screening, and clinical evaluation to be formed actually as a telemedicine encounter. Virtual evaluations should include mealtime observations and swallow trials of various consistencies. The FES and VFSS are considered aerosol generating procedures. And like I mentioned, these are both the gold standards for evaluation. And like I mentioned, this is significant because COVID-19 is transmitted through respiratory droplets. So it's actually recommended to only use these two procedures only in either emergent or urgent cases. And if you have to, it's important to use the proper PPEs during these procedures. So here's a graph showing the FES cases per month, and down here is the COVID-19 cases. And this is done at the Fujita Hospital in Japan, where this study was taken place. So you can see in 2018-19, the FES cases per month stayed stable, and in 2020 during COVID, it dropped significantly. And this is important because like I mentioned, the outcomes of patients that have been treated fast have shown better outcomes. So here's a list of some low aerosol generating procedures and high. So it's recommended to only perform the low generating aerosol procedures. And these include the questionnaire and repetitive saliva swallowing tests. And like I mentioned, the FES and the VFSS are high. And then actually most of the exercises are considered low aerosol generating. But the high ones include voice production exercises, the cough exercises, and the blowing exercises. So tele-rehab has been used in the last few decades. It reduces the risk of infection, prevents isolation, while minimizing the decline in functional status. So the Department of Rehab at the Fujita Health University Hospital, to all their dysphagia patients, they use tele-rehab for the assessment, the swallow trial, range of motion, and muscle strengthening exercises. And they have been very successful without any mechanical trouble and with high participant satisfaction. So here's an image of a physiatrist doing some tele-rehab. And so in conclusion, future direction. So a literature review and case report are considered level five evidence. So the efficacy of dysphagia tele-rehab requires further verification with future studies of better levels of evidence. So as physicians, we need to continue to identify new methods or technologies that allow a safe, comprehensive, and practical encounter for swallowing evaluation and management. Thank you. And I'll open it up for questions. Thanks, Kurt. Really important topic. So swallowing, since they're a little more junior, is a huge part of rehab. In fact, my former chair, that was his specialty. And he worked actually very closely with Fujita University, which is probably the most famous place in the world for swallowing studies. It's really critical for quality of life. I mean, thinking of not being able to swallow and how critical it is, as well as all the complications from it. And a shout out to all our speech therapists around the country. During COVID, they were some of the bravest health care professionals there were. Because yes, you could do these in non-urgent patients, but there were plenty of urgent patients that had to. And they spent more time in Pappers than just about any of our staff or really out there doing heroic work. So great review. And I think some really important things that carry over to other swallowing disorders, as well. So that was very helpful for those that didn't know much about dysphagia. Awesome. Thank you, Dr. Mayer. And then, as Kurt said, any questions from students in the audience? Really cool topic and good stuff, Kurt. Thanks, Kurt. I just wanted to clarify, I was wondering on that graph you were showing with the COVID cases and the feeds. And there was that drop during 2020, I think. And I was wondering if you could just re-explain, was that showing these procedures dropping because it's an aerosol procedure? Or was it like speech pathology or swallowing pathology cases that dropped? Yeah, no, of course. Let me. Yeah, so basically, that chart, it shows the reason because of the drop was it was considered a aerosol-generating procedure. So the Department of Rehab at the Fujita Health University Hospital didn't seem fit to perform these procedures at this time. Got it. Thank you. Oh, thank you. I don't know if I have a question, Kurt. I thought it just was interesting where it was like when you were talking about the preponderance for the loss of taste and smell was like a lot of outpatient folks. It was interesting to me that they didn't have those symptoms when they came in the hospital. And obviously, it makes sense that you're going to go into the hospital for not being able to breathe, let alone not being able to taste. But I just thought that was interesting that we saw so little percentage in that hospitalization population. Yeah, so that report, that paper, I think they tried to explain that, yes, these patients probably had some of these symptoms, but they're dealing with some more serious things like dysphagia and respiratory issues and problems. So those are the reported symptoms. It's interesting how long it lasts, too. So in the long-covered patients, we're seeing a ton of this. It seems to last for six months or more in many, many patients. Move on. Once, going twice. All right, well, we got some other speakers that are gonna have some good content as well. So next up we have Kristen. She's an OMS 4 out of the Midwestern University CCOM. She's gonna be talking about muscle strength and physical performance in patients without previous disabilities recovering from COVID-19 pneumonia. So take it away, Kristen. All right, well, thank you guys for having me. Let me just share my screen. All right, I'm not gonna repeat the article title because it's kind of a mouthful. So thank you, Nathan, for starting it off. As Nathan said, my name is Kristen Vaccaro. I'm in fourth year at Midwestern University, Chicago College of Osteopathic Medicine. And this article was published in the February, 2021 of the American Journal of Physical Medicine and Rehabilitation. So relevance of COVID-19, of course, as we can see, especially right now with the Delta variant and the rising numbers in the U.S. and worldwide. We've also learned from this year that we need instruction on how to wear a mask properly. And on the bottom right corner, I'm from the Chicagoland suburbs. And this was two weeks ago, our Lollapalooza Festival in downtown Chicago, where there's over 110,000 people. And of course, this week we were just told that Chicago is rolling back on their mandates. So now masks are required indoors for both unvaccinated and vaccinated. So we're not out of the woods at all. And this is the WHO dashboard of confirmed cases, new cases, and vaccines administered. And one thing I wanted to point out too, with how COVID's developed over the years is, or over the year, is with India as an example, with the mucormycosis, the fungal infection that they've been dealing with as well. And in the U.S., here's our total number of cases. And if you see on the far right, those are steadily increasing, likely because of the Delta variant. And so I just wanted to give a quick case presentation. This is a case that I, and a patient that I was taking care of last week. I'm on a general internal medicine rotation right now. And so let me just read this off. And if you feel comfortable to use, unmute yourselves and ask some questions or things like that, or use the chat, I have it opened up as well. So this case, a 56-year-old female with a past medical history of hypertension, type 2 diabetes, pulmonary embolism, status post COVID-19. In June of last year, presents to the ED with worsening chest pain and shortness of breath with exertion for one month. She notes diffused whole body muscle aches and intermittent bilateral lower extremity swelling since having COVID. She's no longer taking Eliquis after being told by her PCP it was okay to discontinue after taking it for one year of her PE. So whether you want to add a mention with further questions you'd like to ask on the history, like certain workup that we did, and then the differential, feel free to unmute yourselves or go in the chat. And I'll just give them like a minute or two. I'll take low-hanging fruit and definitely want to get an EKG with the chest pain patient. Yeah, and that was unremarkable. And then one thing while, you know, the chat's through and maybe just kind of going over with like pulmonary embolisms, Virchow's triad with stasis, endothelial injury and hypercoagulable state. So as Kirk mentioned with COVID-19, there's a hypercoagulable state, stasis with prolonged hospitalizations and then endothelial injury can occur just from secondary to like the inflammation that's going on in your body or if there's any other invasive procedures or ventilation and things like that. I'll give another minute or so. Is her chest pain worse with inspiration? Yes. Could we get a CT angio chest? So they actually didn't go straight into a CT angio chest, which was interesting. I was talking to my senior resident about this. Senior resident about this. They actually did a CT cardiac instead of the coronary arteries, which showed a heart score, a calcium score of four, which is pretty, that's pretty low. So, and then the sake of time, further history kind of revealed that she has a history of anxiety that's, you know, she's not taking any medication for. So she also never really did any rehab after her hospitalization. She was hospitalized for six days. She wasn't ventilated, but further workup, we did a stress echo that was unremarkable. And so a lot of this too, that you've seen with like the body aches and lower extremity swelling, they can have like a critical illness myopathy. So just kind of talking about like post COVID-19, like sometimes these symptoms don't go away. Similar to how like the loss of taste and smell doesn't just magically, you know, go away. It can take time. So in terms of her cardiac, it was unremarkable. And so kind of what I've talked about with the COVID-19 symptoms and severity, you know, the symptoms that we've seen, you have the classic ones of shortest of breath, coughs or throat, and you can see like the muscle weakness, the muscle aches, the loss of taste and smell. I put the question marks because we're constantly kind of seeing new symptom presentations occur. One thing I wanted to point out was with nausea, vomiting, and diarrhea, it's been shown that the more kind of systemic symptoms that you're having, especially like diarrhea, it tends to have a worse prognosis. And then this was on the right-hand side are like percentages of cases, which correlates to the table below. This was done from a clinical immunology COVID-19 review where they looked at cases and this was their findings. So most being mild to moderate, but when you get your 5% being critical, that's when you have ARDS, shock, myocardial injury and things like that. So here I was on a infectious disease rotation last rotation, last month, and we looked through a lot of CTs and chest x-rays, and this is your classic, you know, ground glass opacities. And my ID doctor said that, you know, the perfect way to describe ground glass opacities is like looking through stained glass windows. So kind of looking through all of the vasculature, especially right here. And in terms of COVID-19 rehabilitation, again, if you guys wanna unmute yourselves or put it in the chat, just for the sake of time, I'm also gonna have to go, I'm gonna go through each one a little bit quickly, but these are all, and again, I put the question marks in because there's just more and more things we're finding, especially with like COVID rehabilitation that we can do. So like in terms of cognition, there can be patients have reported brain frog, issues with concentration, depression, that's both having the disease as well as the isolation of when we were in lockdown and quarantine. Energy levels can decrease after COVID-19. There's the social, again, isolation, less willing to engage the anxiety of being afraid of getting the disease or being with others who could potentially have it. Nutrition, as Kirk, GI and nutrition, as Kirk mentioned with dysphagia that can limit your ability to have enough food or again, the loss in taste and smell. GI issues is just prolonged nausea, diarrhea. Pain and motory sensory deficits. You can have increased pain sensitivity, rotator cuff issues. You know, this is more specific, but like patients that are proned, you know, sometimes if they're proned inappropriately, like when they're mechanically ventilated and things like that, and those that could be like brachial plexopathy or rotator cuff issues. Skin, you can have pressure ulcers. Sleep, again, can be impacted by mood. Somebody having nightmares or PTSD, there can also be delirium in presence of the hospital situation. And pulmonary, of course, in terms of if you're required to have prolonged home oxygen and things like that. Renal failure, you can have AKI leading to acute renal failure, leading possibly to like hemodialysis. And there's also the possibility of those muscle aches with rhabdomyolysis. Another thing I wanted to mention with COVID-19 rehabilitation is the deconditioning that can happen with these prolonged hospitalizations. And then the deconditioning is also something I'm gonna go through with my article as well. So transitioning to my article, before I start with that, this is just some screening tools that you can do to kind of assess those things that I was talking about with rehabilitation in terms of cognition, physical function, PTSD, and things like that. This is from up to date. So my article, the goal is to describe skeletal muscle strength, exercise tolerance, and symptoms in a cohort of patients recovering from COVID-19 without preexisting locomotor disabilities and to investigate associations between these functional outcomes. So this was a cross-sectional study done in Italy. And this looked at patients that were admitted between April 1st and 30th of 2020. And the inclusion criteria included normoxemia. So that's an SpO2 greater than 94 at rest. And that's at room air. Spontaneous breathing, again, room air. Not tachypneic and afebrile. And the exclusion was any prior locomotor impairment before the infection. And this could be like orthopedic or neurological core mobilities limiting their ADLs. And so in terms of the patient characteristics, so at the time of the study, they looked at patients once they were discharged between April 1st and 30th of 2020. So there was 114 patients admitted, but only 41 of those met the inclusion criteria. And the reason behind most being excluded from the study was because of hypoxemia. In terms of measurements, so this is what my study looked at. So in terms of muscle strength, there was a maximum voluntary contraction of biceps, brachii, and the quadriceps. Exercise tolerant was looked at by the one minute sit to stand test. Physical performance was the short physical performance battery, which looks at, it combines like gait, speed, chair, stand, and balance. And then exercise induced muscle contractile fatigue, which looks at the voluntary contraction of the quadriceps before and after that one minute sit to stand. And then the perceived symptoms of dyspnea and fatigue using the modified Borg scale and the single breath counting tests. And I'll go over the modified Borg scale in more detail. All right, and in terms of the results for this study, on the right hand side is a graphical form of everything I have on the left hand. So in terms of quadriceps, the weakness was seen in 86% of patients and the contraction was 54% of predicted normal value. So in the article, it had all the equations that were used to calculate predicted normal value based on age and things like that. In terms of bicep weakness, 73% of patients showed that with a contraction, 69% of predicted normal value. The one minute sit to stand, 63% of predicted normal value and 24% of patients during the one minute sit to stand desaturated, so less than 94% SpO2. And then this- I have a question about this graph. What is the no C and yes C? I tried to find- Oh, so the no C and yes C means if they had any other comorbidities. Oh. And if I can look, what they called was the presence or not of comorbidities, is what they discussed. Okay. And that was in the, if I go back really quick, the right here, if they had cardiac or pulmonary comorbidities in the patient characteristics. Okay. And then the short physical performance battery had a 74% predicted normal value. And then when I mentioned prior, the Borg scale is a subjective way to find, to assess the intensity of dyspnea or fatigue in the patient. So what you do is you tell them to rate the intensity of their breathing using the scale on the left-hand side. Then you ask the patient to do that. You ask them to do it before and after their activity. So again, it's a way to assess. So maybe my slight dyspnea is someone else's moderate dyspnea, but it is still a way to perceive and scale that for patients. So on the bottom right here is the scale from the study. So at the end of the one minute versus at rest. So you can see at rest, there was nothing to all or very slight dyspnea and fatigue. And then at the end of the one minute sit to stand, there was a moderate dyspnea and very slight to moderate fatigue. And- Five minute warning here, Kristen. Okay, thanks. And then in regards to discharge from these patients, of the 43 that were included, 28 returned home, seven were prescribed one month of tele-rehab, four were transferred to a dedicated pulmonary rehab facility, and one was transferred to another acute hospital. So some discussion with this article. So this was one of the first reports showing impairment assessed in physical performance in individuals with early recovery from COVID-19 infection when they were discharged from the hospital. And then reduced physical performance observed in the patients cannot be ascribed to a prolonged intensive care stay or prolonged mechanical ventilation because of the 43 patients in this that were included in the study, only two of them were intubated and those two patients had hospital days up to nine hospital days. So only two of those were intubated of the 43. Some study limitations. So there's difficulty in assessment of lung diffusion capacity. That's why they use the single breath counting test instead, kind of like Kirk was saying, to assess lung diffusion capacity uses more intensive studying in terms of getting up and close with the patients and getting pulmonary function testing and things like that. So this was a more safe way with the single breath counting that they could do. The lack of a parallel COVID-free control group, that was because of course we remember in Italy the extensive quarantine that they had, so the local lockdown. There may be a lack of external validity. Again, the number of patients were limited at 43 with that restrictive inclusion criteria that I mentioned prior. And then the lack of baseline measures. These patients, all of their measurements were done at the time of discharge. So not being able to do those at the time of admission can not be able to see where each of those patients' baselines were. And in conclusion, the high prevalence of muscle weakness and physical performance impairments in patients recovering from a moderate to severe COVID-19 pneumonia and hospitalized without any previous motor limitation. Just saying that these findings strongly suggest the need to do continued evaluation of patients and that they can have prolonged muscle weakness and have a need for intensive rehabilitation. On future research, COVID-19 in and of itself, obviously more and more studies are being done. And probably will continue to be done with each variant and things like that. Vaccines, as we see vaccines in terms of effects in the future, the vaccine effectiveness. Treatments have already been something that's debated heavily and studied heavily. Health disparities, like we've seen in ethnicities with African-Americans and Hispanics being more impacted in terms of mortality. Economic impact, just in terms of COVID and the economic impact of a lockdown. And children, the isolation effect, the virtual schooling effect. I know kids back to school with masks and things like that. And then COVID effects in children, like prolonged supply. And so my closing comments are just, if you can get vaccinated, let people know about the vaccines and things like that and follow social guidelines. And any questions? I just want to say thank you to the AAP for having me and good luck to all the fellow fourth years in your audition rotations and applications. Thank you, Kristen. Mayor, any initial comments from you? So one question I have is, this study has a really interesting inclusion exclusion criteria, which is probably the most important thing you need to look at when you look at methods in any study. But this one took a really interesting stance on that, which really limited their population by quite a bit. But why do you think they did that? No, it's a really good question. I was also surprised with, in that obviously having 114, then down to 43 just from the inclusion criteria. I feel like they probably did that just to make sure they were looking at muscle. I don't know if there's like muscle strength or like if you're doing a sit to stand, if they're already hypoxemic, that could alter the data. I don't know, it's a good question. Yeah, I think that you're right. I think that's what they're trying to, I think they were trying to control for patients who had critical illness, neuropathies and myopathies. So they eliminated, basically everybody went through the ICU almost, and they eliminated people who had ongoing pulmonary symptoms, which is a minority of patients that soon after COVID. So people who are not tachypneic a month after COVID is a fairly select group. But I think by doing that, they were able to show, look, even in these fairly mild patients, and I wouldn't call this mild, I'd say moderate, I'd call mild COVID for the most part, when they were hospitalized. But even in the mild patients, they had quite a bit of loss of strength and endurance. I mean, that's pretty profound numbers for a pretty mildly effective group. And the numbers are far worse than people who've been through the ICU, of course. But I think this was a fairly early study in COVID and showed even in that pretty select population of relatively healthy COVID patients who didn't have other comorbidities or other problems, they had quite a bit of muscle strength loss and muscle endurance loss. So I think that really demonstrates what COVID's doing. Thank you, Dr. Mayer. And then questions from our audience. Going once, going twice, going thrice. All right, Nimesha, you're ready to rock? Yep. All right, so we have Nimesha Mehta at a, let me give you a full intro here first. So we have Nimesha Mehta, fourth year med student at ToroCom in Harlem. She's gonna be talking about the functional decline in hospitalized patients with COVID-19 in the early months of the pandemic. Take it away, Nimesha. Thank you. Sorry, let me just get the screen share on. So as Nathan said, I'll be talking about functional decline in hospitalized patients with COVID-19 in the early months of the pandemic. So just something to keep in mind with this article, obviously they were doing the study right in the beginning in March when COVID first hit. So just to give you guys some background here, so some of the COVID complications that occur in rehab are having a potential acute change in function, the fact that certain patients that require endotracheal intubation could be faced with problems related to feeding, and to keep in mind that typical protocols that were used were not followed because of the lack of available resources drained by the pandemic. And oftentimes in many hospitals, a lot of the beds in the rehab were given to these COVID patients. So we have to keep that in mind. And due to the severity of the pandemic, assessing the functional impairments in all COVID-19 patients as a result was not possible. So one of the things that they mentioned in the article was how patients with endotracheal intubation would have swelling dysfunction. So I just wanted to include this reference about this article that talks about this. And just to summarize very quickly, it was about post-extubation swelling dysfunction compared in a group of elderly patients compared to younger patients. So it was defined as the inability to swallow 50 milliliters of water within 48 hours after extubation, and this affected 62% of patients. They found that older patients had a higher rate of swelling dysfunction at seven days, 14 days, and 21 days post-extubation, and that it took significantly longer for them to also pass the swallow evaluations than their younger counterparts. And what I found interesting about this was that this was a significant change in patients who didn't have any prior swallowing difficulties. So just something to keep in mind given that COVID-19 did impact a larger population of more elderly folks, at least in the beginning of the pandemic. Not to say that things aren't changing with the Delta variant, so we'll see how that goes there. So just to go over the methods of this study, this was at a tertiary care hospital in the Detroit metro area. So the criteria that they used was they wanted a confirmed diagnosis of COVID-19. And in their study, what they did was they excluded any patients that were younger than 18, and obviously any patients that were not positive during the actual admission. And the way that they conducted the study was that they reviewed the medical records of the patients that were in the hospital. And so their way of assessing the changes in function was based on whether these patients needed any physical therapy, occupational therapy, or speech therapy, whether they had difficulty ambulating, so they needed mobility assistance, and given that many COVID patients did need home oxygen, another one of their criteria was did they need any additional medical equipment other than the home oxygen? And then finally, if they had any dysphagia modifications. So their data analysis was done using something called a Mann-Whitney U-test in the IBM SPS statistics. So I was actually not entirely familiar with the Mann-Whitney U-test until I came across this article. I thought it'd be a good idea just to give you guys an idea of this measure. So you have a null hypothesis, and what you're doing with this test is you're analyzing basically the distribution or the difference in the spread of the dependent variable throughout two independent groups. So normally with a t-test, we compare means, right? So here, by looking at the distribution, we are comparing basically the medians in the two groups. And so you want to assess if the result that you observed in one group is greater in that group than another. So for example, comparing maybe older patients to younger patients again, and seeing if like dysphagia or mobility issues were more prominent in that group versus the younger patients. So I just thought it was interesting that they included the study participant characteristics just because even looking at the race, one of the big topics with COVID-19 has been how this has impacted many patients from different socioeconomic statuses, but also of different races. So after doing some more research, I believe this is better explained by the fact that a lot of ethnic minorities tend to work in service industries. So this means that they're often using public transportation also to get to their work that they rely on heavily. It's that these ethnic minorities also work in more vocational professions that work directly with one-on-one care, maybe such as nursing or nurse aides, anything of that sort. So I feel like that is a good reason why they were impacted more significantly than other groups. So just to go over the results in the first part, we're just gonna look at the discharge results. So there was about 288 patients from anywhere from 20 years old to 95 years old, which is a pretty wide range. Out of those 280, only 239 survived and were discharged. So 63% were discharged home, but around 12% were discharged to a subacute rehab facilitation facility or skilled nursing facility. A few were discharged to LTCH hospice acute care. And unfortunately, 49 patients did not make it to discharge. So again, one thing we were noticing was that the mean age of survival was 60 here compared to the mean age of some of the deceased patients was older at 69, which is consistent with what we were noticing then. So just to break down the results, of these 288 patients and of those that survived, which was the 239, about 45% of those patients experienced a significant change in their functional level. And again, what was really interesting was that 74 of those patients that did experience a significant change were previously independent. So they were fully doing their ADLs and they had full mobility. If not, then 80% also required additional therapy, including durable medical equipment, and even up to 26% had residual dysphagia at discharge. I think, unfortunately, due to the nature of what was being prioritized during the pandemic, 40% of the patients were not able to be seen by a feminine physician, physical therapists, occupational therapists, or speech language pathologist, which is maybe a limiting factor of the study that I'll discuss a little bit later. The average length of stay for these patients with decreased functions was 21 days compared to patients who did not experience the same decline at seven days. So I think, like one of my colleagues mentioned earlier, the deconditioning of staying longer in the hospital probably also contributed to their decreased function. And also one of the significant results was that the same patients that did suffer a functional decline also experienced mechanical ventilation for longer, about like seven days compared to the other group. So let's just talk about maybe the conclusion of this study and some of the limitations that were there. The pandemic definitely limited the extent to which the functional status could be addressed from a physical medicine rehabilitation perspective. Also given that this is a tertiary care hospital, that might also have meant that the department was smaller and that these beds needed to be given to COVID patients. And it wasn't necessarily a priority, which caused many patients to not even be examined, which is unfortunate because I think rehabilitation would have been a significant contributor to improving their function afterwards. And again, this was conducted at the beginning. Another interesting thing was like, even though they noticed that there was a functional decline in these patients, they didn't follow up with them long-term. So we don't actually know long-term if they developed more or new disabilities or whether the functional declines they had improved or worsened, which I thought was interesting. And another point that was interesting was that COVID-19 had a very strong and significant psychological impact on many people. And the study didn't necessarily account for how that physiological impact may have played into the rehabilitation of these patients and how it could have also maybe even exacerbated the functional decline that they were experiencing. So the implications of this are, I think that this was really important because even as a student that was rotating in the beginning of the pandemic, I was on emergency medicine rotations and then medicine rotations. At that time being in the hospital environment, it was obvious that there was a lot of pressure and stress to save these patients. And that was the priority rather than the other needs of these patients. So I think that the study was at least important in illustrating that there needed to be a systemic approach and plan for the different rehabilitation complications in these patients. I think there is a big potential for more research on even monitoring the long-term functions. So does this dysphagia on these patients worsen? Does it get better? Are we able to send home health services now to help these patients get better? So I thought that was significant. And then maybe we can actually prepare a COVID-19 focus protocol so that when future variants, maybe the Delta variant or knock on wood, nothing more severe than that ever comes by, then we can be prepared to incorporate rehab in the initial care process, rather than now looking back and understanding it better. I think that we can streamline a outpatient regimen for these patients to help improve their outcomes, especially the ones concerning like mobility and the ADLs. And I think it's also important that we distinguish the distribution of certain debilities across different age groups. Older patients may be more prone to like mobility issues compared to younger populations. And now that the Delta variant is starting to affect these younger populations, I think it would do them justice to understand what are the most common themes between the two groups and then target that accordingly, if that makes sense. And so right now I'm currently rotating at Jacoby with Dr. Stern. And I was asking her because they have a bigger rehabilitation department than the one I mentioned in the study. I was asking about her experience during COVID and she was actually saying how a lot of doctors came to her and told her that they would maybe need the rehab beds. And she was very adamant that they wouldn't because she recognized very early on the potential for complications in these patients. So actually she referred me to this guide that was put together by Dr. Ambrose and that was used throughout the Montefiore Health System. And this is basically an at-home guide that they were able to recommend to patients once they got home and were recovering from COVID-19. So I just thought it would be interesting to share that with you guys. So the participation criteria for these patients was they couldn't have had a fever in the past week. They couldn't have had any shortness. Aisha. Sorry? Just wanted to give you your five minute warning. Thank you though. Oh yeah, sure. No problem. So the participation criteria, sorry again, was they couldn't have had a fever in the past week. They couldn't have experienced any shortness of breath, palpitations or chest pain while walking and they couldn't have any swelling in their legs. So I think that was really important to mitigate any further complications or potential risks in these patients. And this guide, I do have it physically with me if anyone wants to see a couple of pictures of the exercises. It was divided into three levels based on the weakness and severity of the patients. So level one were patients who were very weak. They had to lie down. And this mostly focused on keeping exercises, very small movements such as hip and knee bends, maybe being able to just sit to the side of the bed and then do sit to stand. And these would be repeated maybe two or three times and then slowly build this up until they can get to level two. So level two would be doing exercises such as bicep curls, shoulder rolls, tummy twists, knee extensions and shoulder abductions. So you can notice how this is a little more challenging obviously than level one requires more muscle movement, more movement in general and the addition of also some light weights to make this more weight bearing. And then finally, after repeating that also for about two to three times, it build up to level three, which included core exercises, which are very difficult, quadriceps stretches, things like upright front rows with maybe slightly heavier weights and then supported squats. So this would also be repeated and over time, this would help the patients improve their function at home. And additionally, they were encouraged to stop if they obviously experienced anything significant such as difficulty breathing, dizziness, exhaustion and chest pain. So I thought that that was actually very interesting and great that they got to give that guideway. So that's the conclusion of my presentation. If you guys have any questions. That's a great job. So you were really impressive. So thanks for doing that. So this study was done really early on in the first months of COVID and things changed a lot in terms of rehab, later in the pandemic. And I know that Cheney University and Michigan University were involved, but certainly other institutions were involved. In the big academic centers, at least really pitched in heavily in COVID. The statistic at Hopkins is 75% of Hopkins COVID admissions were seen by people in our department. So that gives you an idea of how drastically things changed later on in the pandemic. Because we saw early on the problems with that. On the flip side, there were a lot of places early on and later into the pandemic, the community hospitals where the PM&R departments frankly freaked out and refused to see the COVID patients and they got shut down and shut out. And the big losers were the patients and also the hospitals. Hospitals couldn't discharge the patients, couldn't get them out of their ICUs and separate because they weren't getting any rehab. And I think the departments had really chipped in and hit the bull by the horns to do well. Rehab even since it's been up, not down and expanded by the strain of COVID. Which was experienced in a number of places around the country. So, that article I think was a big driving force behind this was that people saw these patients were having a lot of functional decline, a lot of issues. Rehab isn't like the tail end of things as it's traditionally looked at. After the patients like cured of their disease, then they should go to rehab. And that's not how it works. How it works is that really, we start almost immediately when you come to the hospital and you have the whole spectrum of the disease. And now, of course, we have all the post-COVID clinics with long COVID. Thank you. And I'm very curious to see how now with the younger patient populations that are suffering, great more, I guess, extremely than they were with this new variant going out, how the rehab needs change, I guess, for that patient population, whether they experience the same extent of the issues such as dysphagia and mobility, because we're hoping that they hopefully don't have as many comorbidities at this age or the younger age. So, I think that'll be interesting to see. Yeah, we're seeing some of the younger patients now. We're seeing a lot less that are critically ill in our location, because we're in a very high-vaccine state. So, let's not be going through what we went through, you know, six months ago before vaccines came out. But the patients that we are seeing with this, and we have a 25-year-old on the unit right now who's been hospitalized for five months due to COVID, who's still on a ventilator at night. So, it's a lot of the same stuff that we were seeing early on. You know, probably the frequency's less, and you know, there's maybe 25-year-olds that are in this situation, and we saw seven-year-olds and eight-year-olds. But it doesn't seem to be different impairments than we have, but we'll have to wait and see. I don't think it's too early to say that. But the Delta variant won't give us a different... Thank you for the insight there, Dr. Mayer. Any last minute questions from our audience? I know we're on kind of a little bit past nine o'clock, but any questions at all? No questions, but I guess just general question for you, Dr. Merritt, just because I know some of us, I have pretty little COVID exposures because my school kind of took us out early and we haven't really gotten good access to the hospital on that to COVID patients, just because of hospital policies. So, general recommendation for students kind of getting their first exposure to COVID based rehab. Any general advice you'd have for us. So it's taught us a lot of things. I mean, I think we pretty quickly learned that COVID isn't very different from a lot of other things that we treat in rehab. So things like cancer rehab, a lot of the same issues that we had with that. And the advantage that we have as a specialty is we're not an organ based specialty. And something like COVID comes around, it affects every organ system of the body, many severe disabilities too. And, you know, we're really well equipped to do that. And I think, you know, we really need to roll up our sleeves and dig in when something like this happens. And I think we contribute a lot and I think we really appreciate the healthcare system. In terms of what students can do, you know, it's a little tough without the restrictions and the restrictions on visiting students and so forth, which are easing up a little bit, but not much. Post vaccination, hopefully they'll ease up more in the next few months. But, you know, we had students doing a lot of our telemedicine visits, which was interesting because most of our post COVID clinic was done by telemedicine. Now we're doing more and more in person instead of telemedicine. They gave us a lot of, they took away a lot of the restrictions on telemedicine during COVID, but that's not going away, which I think is a shame. Because we can't help but treat people who otherwise can't get into the office. I'm hopeful that some of that will come back, but that's been really disappointing over the last few months as we've seen that disparity. We can't treat people across state lines, for example, for licensed and state patients. It's a good case for national licensure. I'll take the same U.S. MLEs and help license across state lines. Some of you from Ohio can't practice and vice versa. But anyway. So, you know, hopefully you get some exposure, at least in post COVID patients as we move on. It is a shame that a lot of the students were locked out of the great learning experience. We've had a really tough one, unfortunately. So, it's stressful, of course. But it's still exploding. Awesome. Well, thank you, Dr. Mayer, for that good bit of insight. And thanks again for your time. Thank you. and for helping us out with this event. Thanks to Kurt, Kristen, and Misha for some great presentations. Then we'll see some of y'all again for our next journal club in a month or so, where we'll be talking about sports medicine. So stay tuned for that, and thank y'all for coming again. Thanks for inviting me. Thank you, everyone. Thank you, Dr. Mayer.

COVID-19

dyspagia

evaluation

rehabilitative strategy

muscle strength

physical performance

functional decline

hospitalized patients

activities of daily living

rehabilitation interventions