Refusal Post-COVID

The patient was an 80 yo female who was admitted to the ER for abdominal pain and diarrhea. She complained that she has been having intermittent, recurrent  watery diarrhea for 1 month. Stool cultures and blood cultures were negative. Her diarrhea was attributed to recurrent COVID. While in the hospital, she was also found to have acute decompensated heart failure and sepsis secondary to pneumonia. She was transferred to the SNF after discharge from the hospital. 

Past Medical History included obstructive sleep apnea, HTN, DVT, rheumatoid arthritis, depression, glaucoma, dyslipidemia.

When I entered the patient's room, and asked her if she was ready to go to Physical Therapy, she refused and provided a list of reasons why she should not get out of bed to go to therapy. She said that she was a PE teacher for 30 years so she knows the importance of physical activity, but she was too exhausted to get out of bed for physical therapy. I asked if we could do some exercises in bed and she agreed. The videos above are just 2 of the exercises she completed during the session.

The first video is an exercise designed to activate the lower abdominal muscles, one of the exercises I have patients perform geared to activate the abdominals - core activation using ASSISTED PRIMING IN SUPINE (APS) exercises. When I perform these exercises, I ask patients if they could feel their abdominal muscles working. Patients answer in the affirmative every time.

For patients who are medically-complex, we use the standing position as a "catch-all" exercise for activating trunk and lower extremity muscles. When we do this, we are assuming that these muscles are getting activated. How sure are we that this is happening? I often compare the standing position to the toy "Janga." If segments of the body are properly stacked on top of each other, there is probably minimal activation  required to keep the body upright. In addition, we do not know which muscles are being activated to compensate for weaker, poorly activated muscles necessary to maintain the position.

When treating patients who are medically-complex, all the effort of the therapist is usually in physically holding the patient up. When performing APS exercises in the supine position, the skills of a PT are better used in observing patient movement, in correcting movement impairments, and in making sure that the core is activated. I also make sure that the patient is coordinating their breath with their movement, a difficult concurrent skill to practice during ambulation.

The patient exuded positivity after the treatment session, and agreed to be assisted out of bed for dinner.

ASSUMPTIONS

1. APS exercises can be effectively used for activation of core muscles, both upper and lower abdominals.

2. APS exercises is an effective treatment intervention for patients who refuse to get out of bed to go to physical therapy.

3. APS exercises are effective in activating anti-gravity lower extremity muscles for medically-complex patients. This is especially useful during the COVID pandemic.

4. With traditional open-chain exercises, the number of repetitions performed by the patient is determined by the number of times the therapist can lift the patient's lower extremities. APS exercises eliminates therapist fatigue as a factor in patient interventions.

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