Editorial
SARS CoV-2 (COVID-19): lessons to be learned by Brazilian Physical Therapists
Thiago Fernandes Pintoa,b,c, Celso R.F. de Carvalhoa,d,
Corresponding author
cscarval@usp.br
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.
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.
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
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879 "PDF" => 345 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Systematic Review</span>" "titulo" => "Critical evaluation of physical activity questionnaires translated to Brazilian-Portuguese: a systematic review on cross-cultural adaptation and measurements properties" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "187" "paginaFinal" => "218" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3077 "Ancho" => 2500 "Tamanyo" => 259455 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Flowchart for the included studies after systematic review.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Fernanda Gonçalves Silva, Crystian Bitencourt Oliveira, Thalysi Mayumi Hisamatsu, Ruben Faria Negrão Filho, Caio Russo Dutra Rodrigues, Marcia Rodrigues Franco, Rafael Zambelli Pinto" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Fernanda Gonçalves" "apellidos" => "Silva" ] 1 => array:2 [ "nombre" => "Crystian Bitencourt" "apellidos" => "Oliveira" ] 2 => array:2 [ "nombre" => "Thalysi Mayumi" "apellidos" => "Hisamatsu" ] 3 => array:2 [ "nombre" => "Ruben Faria" "apellidos" => "Negrão Filho" ] 4 => array:2 [ "nombre" => "Caio Russo Dutra" "apellidos" => "Rodrigues" ] 5 => array:2 [ "nombre" => "Marcia Rodrigues" "apellidos" => "Franco" ] 6 => array:2 [ "nombre" => "Rafael Zambelli" "apellidos" => "Pinto" ] ] ] ] "resumen" => array:1 [ 0 => array:3 [ "titulo" => "Highlights" "clase" => "author-highlights" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par0005" class="elsevierStylePara elsevierViewall">Measurement properties of most physical activity questionnaires have not been fully tested.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par0010" class="elsevierStylePara elsevierViewall">Construct validation and reliability of most physical activity questionnaires are not acceptable.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0015" class="elsevierStylePara elsevierViewall">Methodological quality of most studies were considered poor.</p></li></ul></p></span>" ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1413355518306142?idApp=UINPBA00007O" "url" => "/14133555/0000002400000003/v1_202005231902/S1413355518306142/v1_202005231902/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "SARS CoV-2 (COVID-19): lessons to be learned by Brazilian Physical Therapists" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "185" "paginaFinal" => "186" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Thiago Fernandes Pinto, Celso R.F. de Carvalho" "autores" => array:2 [ 0 => array:3 [ "nombre" => "Thiago Fernandes" "apellidos" => "Pinto" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 1 => array:4 [ "nombre" => "Celso R.F. de" "apellidos" => "Carvalho" "email" => array:1 [ 0 => "cscarval@usp.br" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Physical Therapy, School of Medicine, Universidade de São Paulo (USP), São Paulo, SP, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Physical Therapy, Universidade de Mogi das Cruzes, Mogi das Cruzes, SP, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Physical Therapy, Centro Universitário das Américas, São Paulo, SP, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "São Paulo Coordinator from the Associação Brasileira de Fisioterapia Cardiorrespiratória e Terapia Intensiva (Assobrafir), São Paulo, SP, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "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." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> 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.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> 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.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">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.</p><p id="par0015" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> 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.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6–8</span></a> 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.</p><p id="par0020" class="elsevierStylePara elsevierViewall">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.</p><p id="par0025" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> 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.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> All these consequences from prolonged stay in the ICU are associated with an increase in morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> 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.</p><p id="par0030" class="elsevierStylePara elsevierViewall">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<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a>; despite that, the pulmonary repercussion of the disease remains poorly known.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> 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.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> 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.</p><p id="par0035" class="elsevierStylePara elsevierViewall">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.</p><span id="sec9005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect9005">Funding</span><p id="par9040" class="elsevierStylePara elsevierViewall">Conselho Nacional de Pesquisa (CNPq).</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec9005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Digital physical therapy in the COVID-19 pandemic" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L.O. 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