Physiotherapy as a Complimentary Treatment in Reducing Viral-Load, Complications, Death, Expedite Discharge and Improve Quality of Life, Exercise Endurance and Capacity in Stroke Survivors With CoViD-19: A Clinical-Controlled Study

Introduction Coronavirus disease 2019 (CoViD-19) is a new pathogen that is highly contagious,
can spread quickly, and it is capable of causing enormous health, economic and societal
impacts in any setting (WHO-China joint mission on CoViD-19). Although COVID 19 belongs to
coronavirinae sub-family and coronaviridae family and different from other previous
coronaviruses such as SARS-CoV and influenza Virus with its unique characteristics. Hence,
building scenarios and strategies only on the basis of well-known pathogens risks failing to
exploit all possible measures to slow transmission of the COVID-19 virus, reduce disease and
save lives.

The COVID-19 virus is unique among human coronaviruses in its combination of high
transmissibility, substantial fatal outcomes in some high-risk groups, and ability to cause
huge societal and economic disruption. The current CoViD-19 pandemic arises from Severe Acute
Respiratory Syndrome Voronavirus 2 (SARS CoV-2) which was first detected as pneumonia of
unknown cause in Wuhan, China in December, 2019. It was declared as public health emergency
of international concern in January, 2020 and global pandemic in February of the same year.
Therefore, with the novel nature, and the continuously evolving understanding, of this
coronavirus demands a tremendous agility in the capacity to rapidly adapt and change
readiness and response planning both for containment and for treatment of the disease and its
emerging sequels.

Before the advent of CoViD-19, different types of coronavirus known in human history include
the alpha coronaviruses HCoV-229E and HCoV-NL63; the beta coronaviruses HCoV-OC43 and
HCoV-HKU1; SARS-CoV, which causes severe acute respiratory syndrome (SARS); MERS-CoV, which
causes Middle East respiratory syndrome (MERS). The definitive diagnosis of CoViD-19 is made
by analysing respiratory samples (collected by aspiration of the airways or sputum induction)
through laboratory tests to identify the virus involved using Real-Time Polymerase Chain
Reaction (RT-PCR) techniques.

Although the American and Europe are mostly affected with Africa being the least affected,
almost all the African countries have had their fair share of the pandemic both in incidence
and in fatality. Although the first fatality was recorded in China, the fatality is now
global. There is no gender variation in the global epidemiology of CoViD-19 but the males are
experiencing higher fatality rate when controlled for age and the presence of comorbid health
problem. However, in Nigeria, the mortality rate is 3.1% with male preponderance (2.2:1 male
to female ratio) and affects more people between 31 years and 40 years.

Between 2 days to 14 days post-exposure, individuals with CoViD-19 can have symptoms ranging
from mild to severe including but not limited to fever, cough, difficulty in
breathing/shortness of breath, sore throat, muscle pain, chills, new loss of taste or smell,
nausea, vomiting and diarrhea. Although the disease is fast spreading across the globe, yet
there is no known standard cure for it neither is vaccine available against the new virus.
However, as the disease manifest its clinical features, various case management/treatment
guidelines are being developed and updated periodically by all national and international
health organisations and the WHO.

Because CoViD-19 is a novel pathogen, the existence of innate immunity in human being cannot
be ascertained. Based on the epidemiologic characteristics observed in China, although there
may be risk factors increasing susceptibility to infection, everyone is assumed to be
susceptible. Since the start of the COVID-19 outbreak, there have been extensive attempts to
better understand the virus and the disease globally. However, key knowledge gaps in the
source of infection, pathogenesis and virulence of the virus, transmissibility, risk factors
for infection and disease progression, surveillance, diagnostics, clinical management of
severe and critically ill patients, and the effectiveness of prevention and control measures
remain. The remarkable speed with which health experts isolated the causative virus,
established diagnostic tools, and determined key transmission parameters, such as the route
of spread and incubation period, provided the vital evidence for gaining invaluable time for
the response.

Although the radiological evidence (Lima, 2020) and laboratory tests are been used as
complimentary approaches to objectify the diagnosis and progression of CoViD-19, the
molecular test of choice for the etiologic diagnosis of SARS-CoV-2 infection is the real
-time reverse transcription-polymerase chain reaction (RT-PCR) test method similar to that
developed for the diagnosis of SARS-CoV. Within 5 to 6 days of the onset of symptoms,
patients with COVID-19 infections have demonstrated high viral loads in their upper and lower
respiratory tract. A nasopharyngeal swab and/or an oropharyngeal swab are often recommended
for screening or diagnosis of early infection. In RT-PCR assay a positive reaction is
detected by accumulation of a fluorescent signal and quantified by the cycle threshold (CT)
values. The CT is the number of cycles required for the fluorescent signal to cross the
threshold (exceeds background level). Cycle threshold levels are inversely proportional to
the amount of target nucleic acid in the sample (the lower the CT level the greater the
amount of target nucleic acid in the sample). Wisconsin Veterinary and Diagnostic Laboratory
(WVDL) real time assays undergo 40 cycles of amplification. Cycle thresholds (CTs) less than
29 are strong positive reactions indicative of abundant target nucleic acid in the sample,
CTs of between 30 and 37 are positive reactions indicative of moderate amounts of target
nucleic acid while CTs of between 38 and 40 are weak reactions indicative of minimal amounts
of target nucleic acid which could represent an infection state or environmental
contamination.

Previous studies had opined that increased age, pre-existing concurrent cardiovascular or
cerebrovascular diseases, the presence of secondary infection and elevated inflammatory
indicators in the blood, CD3+CD8+ T-cells ≤75 cells·μL-1 and cardiac troponin I ≥0.05 ng·mL-1
are predictors of increase in risk of mortality from CoViD-19. With stroke being a leading
cause of death and a major cause of disability worldwide (Bay, 2001), a stroke patient with
CoVid-19 may be said to be in pathway to death. Individuals who have experienced stroke are
faced with a multitude of challenges to restore their quality of life within the limitation
of residual impairment. A stroke patient with clotting disorder is in continuous dynamics of
working against the development of deep vein thrombosis. It is even a great dilemma when a
stroke survivor with clotting disorders has chronic respiratory problem. Much
multi-disciplinary approaches and expertise will be needed for the recovery and
rehabilitation of the patient. Hence, a CoViD-19 patient who ordinarily is susceptible to
developing respiratory complications usually require experts' management especially when the
individual has the high odd ratio of death through the presence of comorbid health such as
restrictive respiratory disorders, diabetes, hypertension and other comorbidities. A stroke
patient with haematological disorders especially of clotting factor disorders. If personal
protective equipment (PPEs) are provided, a physiotherapist should be involved in the acute
care of individuals with CoViD-19 especially when clinical manifestations of CoViD-19
indicated how Physiotherapy can be of great help to CoViD-19 patients. There are also
appropriate Physiotherapy management guidelines for the management of such a patient.

Despite the success of the involvement of physiotherapy in the management of individuals
admitted for SARS-CoV. which has similar clinical features as the novel SARS-CoV2 (CoViD-19),
Physiotherapy are rarely involved in its management especially in low resource countries. The
major targeted aspects for Physiotherapy in critically ill patients include deconditioning,
muscle weakness, joint stiffness, retained airway secretions, atelectasis and avoidance of
intubation and weaning failure. Physiotherapy is helpful in managing patients with severe
acute respiratory distress syndrome (SARS). Physiotherapy focus is to increase mobility,
enhance oxygenation and reduce the risk of ventilator-associated pneumonia. In managing SARS
or Acute Respiratory Disorders' patients, Physiotherapy employed various treatment techniques
such as the use of various chest Physiotherapy procedures, positioning/mobilization,
breathing exercises techniques, coughing techniques, spirometry and Massage/manual techniques
among others. Apart from the fact that physiotherapists have the expertise in management of
CoViD-19 patient, a patient undergoing physiotherapy can also be infected with CoViD-19 as no
one is immune. In order to prevent secondary complication of both the clinical manifestations
of CoViD-19 in one hand and that of their other health problems, patients with CoViD-19
should be treated by physiotherapists from the acute case and even in the intensive care
units/centres. Hence, this study intends to explore success of involvement of physiotherapy
in the acute management of stroke survivors with multiple comorbidities who are diagnosed of
CoViD-19 in reducing odds of developing complications, reduce the odd of death and expedite
discharge.

Rationale/ justification of study Because the novel CoViD-19 can affect anyone including
stroke patients who are receiving physiotherapy, it is highly imperative for a programme that
will incorporate physiotherapy into their treatment to both prevent the possibility of
developing complications as well as death during the isolation treatment. It will also
address their needs for stroke recovery thereby preventing disability and dependency in
activity of daily living due to stroke which will linger during the isolation treatment.

Previous studies had opined that increased age, pre-existing concurrent cardiovascular or
cerebrovascular diseases, the presence of secondary infection and elevated inflammatory
indicators in the blood, CD3+CD8+ T-cells ≤75 cells·μL-1 and cardiac troponin I ≥0.05 ng·mL-1
are predictors of increase in risk of mortality from CoViD-19. Since these factors are either
predisposing factors to stroke or precipitate mortality in stroke patients, a stroke
patient/survivor tested positive for CoViD-19 is in serious dilemma for the likelihood of
developing complications or dying during CoViD-19 isolation treatment. With stroke being a
leading cause of death and a major cause of disability worldwide, a stroke patient with
CoVid-19 may be said to be in pathway to death. Individuals who have experienced stroke are
faced with a multitude of challenges to restore their quality of life within the limitation
of residual impairment. A stroke patient with clotting disorder is in continuous dynamics of
working against the development of deep vein thrombosis. It is even a great dilemma when a
stroke survivor with clotting disorders has chronic respiratory problem. Much
multi-disciplinary approaches and expertise will be needed for the recovery and
rehabilitation of the patient. Hence, a CoViD-19 patient who ordinarily is susceptible to
developing respiratory complications usually require experts' management especially when the
individual has the high odd ratio of death through the presence of comorbid health such as
restrictive respiratory disorders, diabetes, hypertension and other comorbidities. A stroke
patient with haematological disorders especially of clotting factor disorders. If personal
protective equipment (PPEs) are provided, a physiotherapist should be involved in the acute
care of individuals with CoViD-19 especially when clinical manifestations of CoViD-19
indicated how Physiotherapy can be of great help to CoViD-19 patients. There are also
appropriate Physiotherapy management guidelines for the management of such a patient .

Despite the success of the involvement of physiotherapy in the management of individuals
admitted for SARS-CoV. which has similar clinical features as the novel SARS-CoV2 (CoViD-19),
and the fact that some individuals undergoing physiotherapy do contract CoViD-19,
Physiotherapy are rarely involved in its management especially in low resource countries. The
major targeted aspects for Physiotherapy in critically ill patients include deconditioning,
muscle weakness, joint stiffness, retained airway secretions, atelectasis and avoidance of
intubation and weaning failure. Physiotherapy is helpful in managing patients with severe
acute respiratory distress syndrome (SARS). Physiotherapy focus is to increase mobility,
enhance oxygenation and reduce the risk of ventilator-associated pneumonia. In managing SARS
or Acute Respiratory Disorders' patients, Physiotherapy employed various treatment techniques
such as the use of various chest Physiotherapy procedures, positioning/mobilization,
breathing exercises techniques, coughing techniques, spirometry and Massage/manual techniques
among others. Apart from the fact that physiotherapists have the expertise in management of
CoViD-19 patient, a patient undergoing physiotherapy can also be infected with CoViD-19 as no
one is immune. In order to prevent secondary complication of both the clinical manifestations
of CoViD-19 in one hand and that of their other health problems, patients with CoViD-19
should be treated by physiotherapists from the acute case and even in the intensive care
units/centres. Hence, this study intends to explore success of involvement of physiotherapy
in the acute management of stroke survivors with multiple comorbidities who were diagnosed of
CoViD-19 in reducing odds of developing complications and death.

Study objectives

1. To explore effect of physiotherapy on of viral load as measured by Cycle Threshold (CT)
and amount of Nucleic Acid (NA) in the sample of stroke survivors positive for CoViD-19
and their sex age and comorbid heath-status non-stroke individuals positive for
CoViD-19.

2. To explore effect of physiotherapy on development of respiratory complications in the
management of stroke survivors positive for CoViD-19 and their sex age and comorbid
heath-status non-stroke individuals positive for CoViD-19.

3. To explore effect of physiotherapy on use of ventilator in management of stroke
survivors positive for CoViD-19 and their sex age and comorbid heath-status non-stroke
individuals positive for CoViD-19.

4. To explore effect of physiotherapy on death in management of stroke survivors positive
for CoViD-19 and their sex age and comorbid heath-status non-stroke individuals positive
for CoViD-19.

5. To explore effect of physiotherapy on discharge in management of stroke survivors
positive for CoViD-19 and their sex age and comorbid heath-status non-stroke individuals
positive for CoViD-19.

6. To explore effect of physiotherapy on quality of life of stroke survivors positive for
CoViD-19 and their sex age and comorbid heath-status non-stroke individuals positive for
CoViD-19.

7. To explore the effect of Physiotherapy on exercise endurance of stroke survivors
positive for CoViD-19.

8. To explore the effect of Physiotherapy on exercise capacity of stroke survivors positive
for CoViD-19.

Hypotheses

1. There will be no significant difference in the viral-load as measured by CT and NA in
stroke survivors with CoViD-19 who received physiotherapy and their age, sex and
co-morbid heath status-matched non-stroke individuals with CoViD-19 who did not receive
physiotherapy during isolation treatment.

2. There will be no significant difference in the development of respiratory complication
in stroke survivors with CoViD-19 who received physiotherapy and their age, sex and
co-morbid heath status-matched non-stroke individuals with CoViD-19 who did not receive
physiotherapy during isolation treatment.

3. There will be no significant difference in the use ventilator in stroke survivors with
CoViD-19 who received physiotherapy and their age, sex and co-morbid heath
status-matched non-stroke individuals with CoViD-19 who did not receive physiotherapy
during isolation treatment.

4. There will be no significant difference in the death recorded in stroke survivors with
CoViD-19 who received physiotherapy and their age, sex and co-morbid heath
status-matched non-stroke individuals with CoViD-19 who did not receive physiotherapy
during isolation treatment.

5. There will be no significant difference in the rate of discharge in stroke survivors
with CoViD-19 who received physiotherapy and their age, sex and co-morbid heath
status-matched non-stroke individuals with CoViD-19 who did not receive physiotherapy
during isolation treatment.

6. There will be no significant difference in the quality of life in stroke survivors with
CoViD-19 who received physiotherapy and their age, sex and co-morbid heath
status-matched non-stroke individuals with CoViD-19 who did not receive physiotherapy
during isolation treatment.

7. Physiotherapy will not have significant effect on the exercise endurance of stroke
survivors positive for CoViD-19.

8. Physiotherapy will not have significant effect on the exercise capacity of stroke
survivors positive for CoViD-19.

Data Analysis Data will be summarized using frequency, percentage, mean and standard
deviation. Both groups will be analysed for risk for respiratory complications (RC),
likelihood of ventilation (LV) and risk of death (RD) at hospital-isolation admission. The
two groups and difference dichotomies will be compared using independent t-test comparing the
Cycle Threshold Values and the amount of Nucleic Acid in the sample. Analysis of Co-Variance
will be used to compare the Cycle Threshold, Nucleic Acid, Exercise endurance and exercise
capacity across the test periods in the stroke survivors while multivariate regression
analysis will be used to predict odds of complication and survival analysis will be used to
predict death in both groups. Their quality of life will be compared using MannWithney U test
while Friedman Analysis of Variance will be used to compare the quality of life within the
group across the test periods (p<0.05).