Knowledge, Attitude, and Practice of Physiotherapists in COVID-19 ICUs: A National Survey

Background COVID-19 belongs to the beta-corona cluster that spreads enormously via aerosols. Physiotherapists must be knowledgeable about the symptoms, mode of transmission, risk mitigation strategies, and practice guidelines for COVID-19. Objective This study aimed to assess physiotherapists' knowledge of COVID-19 guidelines, their attitude toward this new evolving field, and their practice routines in India's COVID-19 ICUs. Methods It was a cross-sectional study. A total of 600 questionnaires were distributed through e-mail and WhatsApp to physiotherapists using Google Forms between February 2022 and January 2023. The questionnaires consisted of demographics and 23 questions in three sections about the knowledge, attitude, and practice of physiotherapists working in the COVID-19 ICU. Data analysis was carried out using Jamovi. Results A total of 136 responses were obtained from 18 states of India. Of 136 participants, 89 were female (65.4%) and 47 were male (34.6%). The highest level of qualification was BPT (n = 69 (50.7%)), followed by MPT (n = 62 (45.6%)) and Ph.D. (3 (3.7%)). The knowledge about COVID-19 guidelines is fair. Only 21.3% of the physiotherapists received training before being deployed in COVID-19 ICUs, and the CARP protocol was well known by only as few as 10.3%. The criteria advised for close monitoring of patients during treatment was aware by 29.4%. Most physiotherapists have a good attitude toward treating COVID-19 patients; 70.63% strongly agree that physiotherapy is vital in these patients despite the risk of self-exposure, and 64.7% agree that physiotherapy should be initiated during all phases of COVID-19. Physiotherapists follow good practices for COVID-19 patients in the ICU, which is as per the guideline recommendation. Conclusion Physiotherapists working in COVID-19 ICUs have a fair knowledge of the existing physiotherapy guidelines for COVID-19, and they exhibit good attitudes and practice patterns.


Introduction
COVID-19 (coronavirus) belongs to the beta-corona cluster that spreads enormously via aerosols [1].It reaches the lung and the angiotensin-converting enzyme (ACE-2), seen in type I and II alveolar cells [2].Normally, alveolar cells synthesize and secrete surfactants, implement the xenobiotic mechanism, aid water movement across the epithelium, and regenerate the alveolar epithelium postlung injury [3].When the cells are damaged, all these functions will be afected, causing respiratory problems, other systemic manifestations, and even death.Fever, cough, myalgia or fatigue, headache, rhinorrhea, sneezing, sore throat, gastrointestinal symptoms, pneumonia, and complicated dyspnea are some of the clinical presentations of COVID-19.Symptoms may advance from mild to severe during a week or more; deterioration may be sudden and disastrous [4,5].Te frst case of COVID-19 was reported in China in December 2019, and since then, the virus has spread rapidly.On 30 th January 2020, the World Health Organisation (WHO) announced it was a public health emergency of international concern [1,6].As of 2 nd December 2021, globally, more than 263 million people have tested positive [7].Te knowledge of this evolving disease is incomplete.
Coronaviruses often mutate and recombine, thus challenging our understanding and clinical management of the disease.All viruses change over time, and these changes may or may not afect their properties, such as severity, speed of spread, therapeutic medicine, and diagnostic tools.Omicron and its subvariants are the recent COVID-19 variants [8].Infection severity, vaccine efectiveness, and available treatments are still being evaluated [5].Tis global pandemic has brought the world to a standstill, leading to morbidity and mortality [9].
Given the newness and urgency of this pandemic, the signifcance of rehabilitative care has increased due to its potential impact on mortality, morbidity, duration of ventilation, and length of ICU/hospital stay [10].Te presence of physiotherapists in the ICU contributes to the early recovery of the patients.All physiotherapeutic approaches require close contact and are considered to generate aerosols, raising safety concerns for therapists [11].Appropriate knowledge and use of personal protection equipment (PPE) are vital.A survey conducted by Husain MA et al. (2021) in Saudi Arabia indicated that the degree of knowledge about COVID-19 preventive measures among physiotherapists is considered high, but few lacked knowledge of the application of PPE [12].Physiotherapists must be knowledgeable about the disease symptoms, mode of transmission, risk mitigation strategies, diagnostic measures, and practice guidelines for COVID- 19.
In March 2020, Tomas et al. provided physiotherapy recommendations that were internationally endorsed by several associations worldwide.Tis includes planning and preparing a physiotherapy workforce, a screening tool for determining the category of patients requiring physiotherapy, recommendations on selecting physiotherapy treatments, and using PPE, which plays an essential role in preventing the spread of the virus.An update to these recommendations has been published in 2022 [13,14].
An evidence-based national consensus was conducted in 2020 to provide specifc physiotherapy practice recommendations in the COVID-19 acute care Indian setup, which was endorsed by the Indian Association of Physiotherapy (IAP).Te aim of the treatment and recommendation were categorized according to the patient's presentation, i.e., mechanically ventilated or nonmechanically ventilated in the COVID-19 ICU [11,15].Both guidelines are similar, except that the international guideline states that there is no evidence for using incentive spirometry in COVID-19 patients.In contrast, the nationally accepted guideline advises its use in stable patients to improve volume and ventilation.
Chest physiotherapy is most efective in reducing the pulmonary infection rate, and it can improve quality of life by improving respiratory function.It includes percussion, vibration, postural drainage, and airway suctioning techniques.Chest physiotherapy should be given only when benefcial and individualized according to the patient's presentation [9,16].It has been found that active breathing exercises have improved pulmonary ventilation, mobilization, and excretion of secretions and stimulate respiratory muscles.Positioning a patient posttreatment or using positional treatment alone helps in increasing the ventilation-perfusion ratio.Exercise therapy improves immunity and reduces complications favoring functional recovery in patients afected by COVID-19 [17].
Due to the increase in COVID-19 patients admitted to ICUs, the pandemic has challenged physiotherapists to apply their knowledge and skills to treat these patients [17].Since this is an evolving area of practice and even though physiotherapy interventions have been proven benefcial, the knowledge, attitudes, and practices among physiotherapists in Indian ICUs remain unexplored.Tus, the study aims to explore physiotherapists' knowledge, attitude, and practice patterns in COVID-19 ICUs in India.Te survey questionnaire was prepared using Google Forms.It consisted of 23 questions divided into three sections and the demographics of the respondents like age, gender, the highest level of qualifcation, the state where they work, and months of experience.Te investigators designed the questionnaire to focus on the knowledge, attitude, and practice of physiotherapists working in COVID-19 ICUs in India.

Methods and Methodology
Section A included seven questions taken from the guidelines aimed to assess physiotherapists' knowledge regarding physiotherapy guidelines, Section B included four questions regarding physiotherapists' attitudes toward patient care, and Section C had twelve questions focused on assessing their practice patterns in COVID-19 ICUs.Mostly, the items were close-ended/multiple-choice questions to avoid self-bias.An extra column was added where the respondent could add to the already provided options where relevant.In some places, choices of multiple answer selections were also ofered.Te entire questionnaire (given in Appendix 1) took about 15 min to fll out.
Hospitals having COVID-19 ICUs were shortlisted by the National Accreditation Board for Hospitals (NABH), the Medical Council of India (MCI), and IAP websites, and 600 questionnaires were mailed requesting to circulate among physiotherapists.Te questionnaires were also distributed through e-mail, Facebook Messenger, or WhatsApp.Tey included a hyperlink that directed participants to the survey on a web page.Te investigators priorly informed the scope and objective of the study.Participants flled out the questionnaires only after giving their consent for the study.
To ensure a good response rate, a span of 3 weeks was given to participants to return the flled questionnaire.If a response was not obtained within the stipulated period, then two reminders were sent with a gap of one month.After that, nonresponders were excluded from the study.
Before starting the study, the survey questionnaire was submitted to 5 experts: cardiopulmonary physiotherapists (n � 4) and a faculty from the Department of Community Medicine (n � 1).All feedback was taken, and appropriate changes were made.Later, the content validity index (CVI) was used to measure the validity of the questionnaire.Tis is the most widely used approach for the development of the content validity of an instrument.Te questionnaire's relevance was calculated similarly on a 5-point scale: 1: irrelevant, 2: slightly relevant, 3: somewhat relevant, 4: moderately relevant, and 5: extremely relevant through Google Forms.
To judge a scale as having excellent content validity, it should be composed of items with I-CVIs that meet Lynn's (1986) criteria (I-CVI of 1.00 with 3-5 experts and a minimum I-CVI of 0.78 for 6-10 experts) and it should have an S-CVI/Ave of 0.90 or higher [18].
Te fnal draft of the survey was designed according to the suggestions given by the subject experts.

Data Analysis.
After the data were collected, they were exported to Jamovi (version 2.3.21)software for analysis.
Frequency, cumulative frequency, and percentages of all responses have been obtained along with bar charts to summarize the categorical data considered in the study.
Furthermore, we used one-way ANOVA to determine whether there is statistical evidence of a signifcant association between diferent variables.

Content Validation.
Te validity of the questionnaire was determined using CVI and is explained in Table 1.
Te proportional relevance (PR) for expert 1 is 0.9, expert 2 is 0.9, expert 3 is 1, expert 4 is 0.9, and expert 5 is 1.Te score content validity average based on I-CVI is 0.97, the score content validity average based on PR is 0.94, and the score content validity average based on universal agreement is 0.91.
From the values obtained, we can conclude that S-CVI Ave based on I-CVI, S-CVI Ave based on PR, and S-CVI Ave based on UA meet a satisfactory level.Tus, the scale of the questionnaire has achieved satisfactory content validity [18].
Only 14 physiotherapists knew the COVID awake repositioning proning (CARP) protocol really well (10.3%),42 knew the protocol (30.9%), 49 had heard of it (36%), and 31 did not think they had heard of it (22.8%)(Figure 2(d)).While the majority of the responders (n � 123 (90.4%)) thought prone positioning was applicable in COVID patients, only (n � 43 (31.6%)) were aware of the recommended duration for the CARP protocol (Figures 2(e) and 2(f )).Criteria for close monitoring "fall of oxygen saturation more than 3% or saturation of <96% at rest" were chosen by 40 (29.4%)responders, while 85 (62.5%) chose "fall of oxygen saturation more than 10% or saturation of <85% at rest, 8 (5.9%) were not sure, and 3 chose "none of the above" (Figure 2(g)).Only 39 (28.7) responders were able to choose the category of patients rightly indicated for physiotherapy, i.e., "mild symptoms and/or pneumonia and coexisting respiratory or neuromuscular comorbidities and current or anticipated difculties with secretion clearance; mild symptoms and/or pneumonia and evidence of exudative consolidation with difculty clearing or inability to clear secretion inadequately; severe symptoms suggesting pneumonia/ lower respiratory tract infection; chest X-ray/CT scan/ lung ultrasound showing changes consistent with consolidation; and any patient at signifcant risk of developing or with mild evidence of signifcant functional limitation" (Figure 2

(h)).
A total of 52 (38.2%) rightly thought that strengthening skeletal muscles and recovery of activities of daily living should be contraindicated in patients admitted to COVID-19 ICUs, as they can increase the load on the respiratory system and increase the risk of distress, while 64 (47.1%) think this is not contraindicated.Te rest 20 (14.7%) are still determining (Figure 2(i)).
In total, only 45.47% of the participants gave the appropriate answers to knowledge-related questions.
Four case-based questions were asked, and the responses are given in Tables 3-6.
Table 7 shows the association of diferent characteristics with knowledge, attitude, and practice.
Subgroup analysis revealed that there is a signifcant association for knowledge with qualifcation, designation, age, and duration of work.Tere is also a signifcant association for practice with qualifcation, age, and duration of work.

. Discussion
Te present study has assessed the knowledge, attitude, and practice of physiotherapists working in COVID ICUs in India.
COVID-19 breakout was the most critical health emergency in the recent decade; such an event with exceptional magnitude was required to increase ICU capacity, which in turn demanded appropriately trained healthcare staf as the process included the deployment of non-ICU healthcare professionals [19,20].
Several studies were conducted to assess the knowledge and attitude of physiotherapists about COVID-19; these were conducted regarding the source of awareness, clinical symptoms, diagnostic measures, mode of transmission, risk mitigation, and preventive measures.Tese studies found that physiotherapists are sufciently knowledgeable about COVID-19 [21][22][23][24].However, these studies had not assessed (i) the knowledge and attitude of physiotherapists, specifcally in those who worked in COVID-19 ICUs, and (ii) awareness of gold standard rehabilitation protocols.Tus, we aimed to assess physiotherapists' knowledge of the existing physiotherapy guidelines for COVID-19.To the best of our knowledge, this is the frst study to assess the knowledge of physiotherapists regarding the existing physiotherapy COVID-19 guidelines.Te fndings of our  Te Scientifc World Journal sedation and administering vasoactive medication, continuous positive airway pressure services, and particularly on PPE and infection control techniques [25].Physiotherapists being an essential part of the ICU team are required to have skills in managing the needs of patients according to the symptoms, which include awareness of presuction positioning, suctioning techniques, ability to judge and increase FiO 2 , and use of maneuvers such as percussion, vibrations, and shaking [26].Although many did not receive any training, most of them knew the PPE donning and dofng sequence (89.7%); this is in line with other studies assessing physiotherapists' knowledge about COVID-19 infection prevention control measures [12,27].41.2% were aware of the CARP protocol, but only 31.6% knew the recommended duration.According to the guidelines, close monitoring is indicated when there is a fall in oxygen saturation of more than 3% or saturation below 96%, of which 71.7% of the responders were unaware.In our study, it was found that only 28.7% of responders were able to choose the category of patients indicated for physiotherapy intervention correctly, and this is not in accordance with a recent study conducted that stated 90% of the participants were aware of physiotherapy-specifc guidelines for treating patients with COVID-19 [28].In total, only 45.47% of the participants gave the appropriate answers to knowledge-related questions, indicating insufcient knowledge about the existing guidelines.
Te exploration of the attitude of physiotherapists toward working in ICUs revealed that 70.6% of the responders thought that physiotherapy was a vital component of ICU management despite the risk of exposure, and this was in line with the fndings obtained in a study by Mohamed et al., in Saudi Arabia, about knowledge, attitude, practice, and perceived job stress among physiotherapists, which revealed Te Scientifc World Journal that 75.8% of the responders expressed their disagreement that they are concerned about getting COVID-19 while participating in inpatient care [29].Tis shows a positive attitude of physiotherapists consistently toward COVID-19, despite self-exposure risk, by realizing their crucial role in their management.Moreover, most of the responders in our study thought that physiotherapy as a multidisciplinary approach should be initiated during all phases of COVID-19, be it in the ICU, where the patient is critically ill, or even after discharge.It was estimated that 80% of the infected patients with COVID-19 developed one or more long-term symptoms, lasting from several months to a year or more.Fatigue, headache, attention disorder, hair loss, dry cough, productive cough, and dyspnea were some of the most common symptoms.Research suggests that multidisciplinary teams are crucial to developing preventive measures, rehabilitation techniques, and clinical management strategies with whole-patient perspectives designed to address Te Scientifc World Journal long-term COVID-19 care [30].While the role of the physiotherapist in the COVID ICU is paramount, 51.5% of the responders in our study chose "seldom/never" when asked if their opinion was taken before deciding to shift the patient to the ward.Te fndings of our study indicate that physiotherapists working in COVID-19 ICUs showed a positive attitude toward treating patients with COVID-19.
Te present study showed that the majority of the physiotherapists consistently monitored vitals pretreatment and posttreatment; this is in accordance with the physiotherapy guidelines for patients with COVID-19, which states that all must be screened, assessed, and monitored continuously during and postphysiotherapy treatment [14,15].Prone positioning is highly recommended in critically ill patients infected with COVID-19.It was found to improve the oxygen level by optimizing lung recruitment and improving the ventilation/perfusion index.However, this is not indicated in all patients.Several contraindications, such as increased intracranial pressure, spinal instability, pregnancy, and open abdominal wounds, should be performed only when sufcient technical resources are available [17].Te guidelines recommended a prone position for 12-16 hours a day.Our responders commonly practice prone and frequent changes in position.Similar fndings have been found in an earlier study conducted in Brazil [31].In the current study, 41.9% of the physiotherapists were always involved in closed suctioning, while 32.3% still always used open suctioning despite the risk of creating an airborne transmission of COVID-19 treatment.Our fnding contradicts Trojman A et al., whose results stated that 97.8% of physiotherapists adhered to the guidelines and did not use open suctioning in ventilated patients.
Patients admitted to the acute care setup can be categorized into mild, moderate, and severe.Recommendations for physiotherapy intervention in these categories have been provided in the guidelines; it is the responsibility of physiotherapists to use these recommendations along with their clinical judgment.Our study participants showed that they follow best practice behavior in treating patients in COVID-19 ICUs, which aligns with physiotherapy guidelines for COVID-19.In patients presenting with mild symptoms, i.e., patients on low-fow oxygen, room air, or home isolation, breathing exercise was used by 97.8% of them.Te most frequently used airway clearance techniques were ACBT, ACBT-FET (79.4%), and postural drainage (61%).Incentive spirometry was used by 69.8% of the participants, which can improve lung volume and ventilation in patients on nasal prongs or room air.Early mobilization is highly recommended in these patients as this could prevent secondary complications such as ICUacquired weakness; in the present study, active range of motion exercises were the choice of mobilization therapy, and a good number of participants (69.9%) were always involved in ambulating the patients within the ICU.
In patients presenting with moderate symptoms, i.e., patients receiving a high-fow oxygen (HFO) system or Venturi mask and whose SpO 2 drops during activity, the respiratory physiotherapy techniques most commonly used by our participants were relaxation, active breathing, and bronchial hygiene therapy, including thoracic expansion exercises, postural drainage, percussion, and vibration.More than half of the responders practice therapeutic positioning, including CARP and prone positioning, which is advised in these patients to increase oxygen saturation and delay or reduce the need for intubation.Te diferent mobilization therapies used range from active, active-assisted, and passive range of motion depending on the patient's level of consciousness and ability to follow commands, and only 29.4% of participants were involved in ambulating these patients.Te Scientifc World Journal 13 Tis could be because of several reasons such as fatigue, breathlessness, and desaturation with activity; thus, close monitoring to screen for activity-induced desaturation is mandatory, and when required, oxygen titration in consultation with a physician should be performed [14,15].Te physiotherapy recommendations given for patients on MV and ECMO are similar.Te result from our study also shows similar practice patterns in both categories.Te most frequently used techniques were prone positioning, postural drainage, and closed suctioning.In mobilization therapy, passive-and active-assisted ranges of motion are used.Although ambulation is not contraindicated in mechanically ventilated patients or those on ECMO, most of our responders seldom or never practiced it.Tis could be due to a lack of personnel or needing to be experienced in doing so.
Subgroup analysis showed a signifcant association for knowledge and practice with qualifcation, designation, age, and duration of work.Tis could be due to greater exposure to similar situations, patient interactions, etc. Tose specialised in cardiopulmonary physiotherapy would have better knowledge about COVID-19 which in turn will increase with other factors such as experience, exposure, or even age [32].
However, there is no association of attitude with any characteristics, and all expressed positive attitudes.A good attitude is vital for a healthcare professional.Tere is a big discussion going on all over the world as to how to improve the attitude of health professionals.In recent times, a new curriculum called Attitudes, Ethics, and Communication (AETCOM) has been integrated for undergraduate students which will run across years.Te learning outcomes enable them to assess the communication needs of the patient/ community.As India has made AETCOM compulsory in the frst year, core skills in communication (listening, interpreting, body language, writing, reading, and reasoning) are inculcated, and the learner can communicate effectively with patients, the community, and colleagues in a respectful nonthreatening, nonjudgmental, and empathetic manner [33].
Tis study has some limitations.A smaller sample size and bias of responders toward the states of Karnataka, Maharashtra, and Kerala could mean that the study results may not refect the practice patterns of physiotherapists in Indian COVID- 19 ICUs.More open-ended questions would have been able to provide better qualitative data.

Conclusion
Te results of the current study may add to the limited evidence available regarding the knowledge of physiotherapists about the existing COVID-19 practice guidelines, their attitude toward the disease, and the practice pattern used in COVID-19 ICUs.Te results show that the number of females working in COVID ICUs was greater than that of men, and their highest level of qualifcation was BPT followed by MPT.Te knowledge and practice patterns were better among physiotherapists with higher qualifcations and years of experience.Te study suggests that the attitude of physiotherapists is appropriate and there is no signifcant association between qualifcation, experience, or designation, which shows that all the physiotherapists irrespective of the diferences show promising attitudes toward disease and their patients, while knowledge regarding the physiotherapy guidelines for COVID-19 needs to be more satisfactory.Tis could be because of the need for more educational support for them.Most physiotherapists did not obtain any training before being deployed in COVID-19 ICUs.Additional education and organizational support may enhance the quality of service provided to patients and prepare the physiotherapists to make appropriate decisions, which may also reduce their work-related stress.

Clinical Signifcance.
Te study results will help us understand physiotherapists' knowledge regarding the existing COVID-19 guidelines, their attitude toward the disease and patient management, and practices in COVID-19 ICUs.Te study results found that most physiotherapists involved in COVID-19 patient care had bachelor's degrees and lacked training; there is also a signifcant association of knowledge and practice with qualifcation, age, and experience.Tus, the study shed light on the need to impart specifc educational training or awareness programs before deputing a physical therapist, especially if they are new graduates with no prior experience in a similar feld for intensive care in COVID-19 patients.Tis would help improve the physiotherapy service provided, thus improving the treatment outcome which is the ultimate goal.

Future Recommendations.
Future studies need to include a qualitative approach to obtain more details about the challenges and components of physiotherapy practice.

Figure 3 :
Figure 3: (a) Response rate for "please assume for a moment about exposure to the therapist and answer the question, physiotherapy service is essential in COVID-19 ICU?" (b) Response rate for "which phase of COVID do you think physiotherapy should be initiated?"(A) Acute/ mild.(B) Critical.(C) Postacute and discharge.(D) All of the above.(c) Response rate for "do you follow a multidisciplinary approach?"and "is the physiotherapists' opinion taken before shifting the patient out of COVID ICU?"

Table 2 :
Demographics and qualifcations of the participants.

Table 3 :
Frequency of diferent treatment methods used in patients presenting with saturation: mild or no change at rest (SpO 2 of 92-94%); symptoms: none; HD CT score: <8; oxygen support: low-fow oxygen or room air/home isolation.

Table 4 :
Frequency of diferent treatment methods used in patients presenting with saturation: drop in SpO 2 during activity; symptoms: fever, cough, and breathlessness; HD CT scan: 9-19; oxygen support: high-fow oxygen (HFO) system/Venturi masks.

Table 5 :
Frequency of diferent treatment methods used in patients presenting with saturation: high FiO 2 and PEEP to maintain oxy- genation; symptoms: altered mental status; signs of ARDS (mild to severe); HD CT scan: >15; oxygen support: MV or noninvasive ventilation (NIV).

Table 6 :
Frequency of diferent treatment methods used in patients presenting with saturation: needs high FiO 2 and PEEP to maintain oxygenation; symptoms: ARDS, multiorgan failure, sepsis, and shock; oxygen support: MV or with ECMO.

Table 7 :
Association of diferent characteristics with knowledge, attitude, and practice.