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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2023 | Month : November | Volume : 17 | Issue : 11 | Page : YD01 - YD04 Full Version

Physical Therapy Management of a COVID-19 Patient on Extracorporeal Membrane Oxygenation: A Case Report

Published: November 1, 2023 | DOI:
Amany Raafat Mohamed, Ahmed Refaat Abd El Aziz Taha Malik, Ahmad Galal Zaki Elbahrawi, Hisham Mohamed Hussein, Ahmed Abdelmoniem Ibrahim

1. Faculty, Department of Physical Therapy for Internal Medicine, Suez University, Physical Therapy, Cairo, Egypt. 2. Faculty, Department of Physical Therapy, Kasr Al-Aini Hospitals, Cairo University, Giza, Cairo, Egypt. 3. Faculty, Department of Physical Therapy, Kasr Al-Aini Hospitals, Cairo University, Giza, Cairo, Egypt. 4. Faculty, Department of Physical Therapy, College of Applied Sciences, University of Ha’il, Ha’il, Saudi Arabia. 5. Associate Professor, Department of Physical Therapy, College of Applied Sciences, University of Ha’il, Ha’il, Saudi Arabia.

Correspondence Address :
Ahmed Abdelmoniem Ibrahim,
Associate Professor, Department of Physical Therapy, College of Applied Sciences, University of Ha’il, Ha’il, Saudi Arabia.


Coronavirus Disease-2019 (COVID-19) can be classified as a respiratory disease that ranges from pneumonia to critically ill cases. Extracorporeal Membrane Oxygenation (ECMO) is a therapeutic procedure that can treat severe cases of respiratory failure. Hereby, the authors present, a 28-year-old case of Acute Respiratory Distress Syndrome (ARDS) young patient with COVID-19 on ECMO therapy, presenting with complaints of weakness, decreased mobility and function, and depression. The patient has received physical therapy interventions during the hospitalisation period. Respiratory, mobility, activity level, and psychological assessments were done before and after treatment using blood gases, the Intensive Care Unit (ICU) Mobility Scale, the University of Michigan scale, and the Hamilton Anxiety and Depression Rating Scale, respectively. There was an improvement in respiratory function, mobility (scores increased from 0 to 1), activity level (scores increased from 0 to 3), and psychological well-being (depression scores decreased from 18 to 15, and anxiety scores decreased from 20 to 14) after physical therapy. The treatment resulted in better recovery and prevented the worsening of the COVID-19 disease scenario.


Coronavirus disease-2019, Physical therapy modalities, Venovenous extracorporeal membrane oxygenation

Case Report

A 28-year-old male patient was admitted to the critical care department with severe ARDS due to bacterial pneumonia caused by COVID-19. He presented with rapid heartbeat, breathlessness, and confusion. The patient had a past medical history of Graves’ disease for 10 years and complained of an enlarged thyroid gland, weight loss, irregular heartbeat, fatigue, and muscle weakness. The patient underwent Polymerase Chain Reaction (PCR) testing for COVID-19 about five times every two weeks. The test was positive three times within a span of 45 days, and then the patient tested negative after one more month. A tracheostomy was done as the patient required prolonged Mechanical Ventilation (MV). Subsequently, the patient developed a left-side thoracic haematoma (pneumothorax and haemothorax), and two chest tubes were inserted. Venovenous ECMO (VV ECMO) was initiated after MV failure (Table/Fig 1). The patient’s vital signs before ECMO were as follows: temperature of 38.2°C, heart rate of 105 bpm, blood pressure of 129/78 mmHg. After ECMO, the temperature was 36.9°C, heart rate was 79 bpm, and blood pressure was 120/70 mmHg. The patient remained fully conscious and well-oriented. The patient received the following medical treatment: antibiotics, antivirals, and anti-inflammatory medication for four weeks, including Tienam 2 g daily, Tavanic 750 g daily, Penfinix 600 mg twice daily, and Carbimazole 10 mg twice daily. Additionally, the patient took Colistin 9 mL, Solupred 5 mg, Cipralex 20 mg, Respiridal 1 mg, and Procoralan 75 mg as part of the antidepressant treatment. Nutritional support was provided through Aminoliban, Addamel 25%, N-acetylcysteine (NAC) 600 mg, Fresubin 50 mL, and Cevarol 2 g.

After the patient achieved haemodynamic stability, physical therapy intervention was initiated in the 4th week of admission to mitigate complications arising from being bedridden and improve lung aeration. Various physical therapy procedures were implemented twice a day for approximately 30 minutes. These procedures included active range of motion exercises for the upper and lower limbs (1 to 3 sets of 8 to 10 repetitions of 5 active range of motion), airway clearance techniques like positioning, chest wall vibration, percussion, segmental breathing exercises, diaphragmatic breathing exercises (2 sets of 10 minutes per set), and Manual Hyperinflation (MH) for 15 minutes per session, two time/day for two weeks. The rehabilitation protocol adhered to legal and international requirements, specifically the Declaration of Helsinki from 1964. The patient received information about the procedure and gave written consent before evaluation. The physical therapy rehabilitation program consisted of two daily training sessions, averaging 30 minutes each. During the first and second weeks, the program focused on modified positioning (sitting, side-lying on both sides) combined with chest wall oscillation and vibration (every 1-2 hours for 5 minutes). Additionally, active range of motion exercises for the upper and lower limbs (1 to 3 sets of 8 to 10 repetitions of 5 active range of motion), diaphragmatic breathing, and segmental breathing (2 sets of 10 minutes per set) were incorporated (1),(2). Furthermore, MH was employed to stimulate coughing, facilitating the mobilisation of airway secretions towards the larger airways (Table/Fig 2) (3).

After two weeks, the patient started cough assist sessions with the previous protocol. This began with inspiratory pressures between +10 and +15 cm H2O and expiratory pressures between -10 and -15 cm H2O. The patient continued with several cough cycles, 4 to 6 in a session, with a pause of 2 to 5 seconds between cough cycles. A rest period of 30 seconds was used before repeating the session. During the rest period, the patient returned to their normal oxygen or ventilation settings.

Specific evaluation for ECMO COVID-19 patients:

1. The ECMO flow, ventilation settings, and venous oxygen saturation (SVO2) were continuously monitored via the ECMO circuit during the patient’s mobilisation (Table/Fig 1) (3),(4).
2. The activities for ECMO patients were measured using the University of Michigan scale for assessing the safety and efficacy of early mobilisation in the ICU (Table/Fig 3) (4),(5).
3. Assessment and meachanical ventilator setting has been presented in (Table/Fig 4).
4. Mobility was measured using the ICU Mobility Scale (Table/Fig 5) (6).
5. Respiratory assessment, including venous blood gases and oxygen saturation, should be done before and after physical therapy treatment (Table/Fig 6) (7).
6. Psychological assessment was done using the Hamilton Anxiety and Depression Rating Scale (HAM-D-HAM-A) (Table/Fig 5) (8).

In the third week, the patient followed the same previous program, along with trunk (abdominal ex) and cough assist sessions. The frequency remained at 4 to 6 cough cycles per session, with a pause of 2 to 5 seconds between cough cycles. Throughout the physical therapy sessions, vital parameters and the patient’s well-being were evaluated and monitored. If the patient became haemodynamically unstable, the sessions were terminated.

Follow-up and outcomes: Follow-up and outcomes: The assessments performed using the previous specific COVID-19 evaluation showed improvement in several functions for the patient. Regarding ECMO flow, ventilation settings, and SVO2, the initial assessment of ECMO blood flow rate, sweep flow, and SVO2 was 3400 rpm, 8 L/min, and 47.6%, respectively. After the physical therapy program, they were 3370 rpm, 12 L/min, and 60%, respectively. The final assessment showed 2945 rpm, 6 L/min, and 65%, respectively (Table/Fig 1). Regarding the ventilator settings, the patient was initially dependent on ventilation with Pressure Control (APRV) mode, with a pressure support of 20 cmH2O, Fio2 of 60%, PEEP of 7, and minute ventilation of 4.13 L/min. After the physical therapy sessions, the ventilator settings improved to Continous Positive Airway Pressure (CPAP) mode, then T-tube mode, with Fio2 of 50%, PEEP of 5, and minute ventilation of 6.5 L/min.

Additionally, there were improvements in the patient’s activities, measured using the University of Michigan scale (4),(9). The patient’s score started at zero, indicating no mobilisation. Then the score progressed to one, indicating the ability to turn in bed and sit in bed while elevating the head of the bed. There were also improvements in mobility, transitioning from no activity (being passively rolled or passively exercised by staff without active movement) to activity in bed with an assistant (assisted by staff and involving active sitting over the side of the bed with some trunk control).

Respiratory assessments, including venous blood gases, blood tests, and oxygenation saturation, were performed before and after physical therapy treatment, showing improvement. Psychological assessment was done using the Hamilton Anxiety and Depression Rating Scale (HAM-D-HAM-A) (Table/Fig 5) (8). Furthermore, the patient’s condition gradually improved over time, and they were weaned from the ventilator and ECMO. Subsequently, they started online outpatient rehabilitation, which lasted for approximately three months.

The pre- and post-intervention radiographic findings are shown in (Table/Fig 7),(Table/Fig 8).


The present case report applied to ARDS COVID-19 patients on ECMO support measured mobility, activity level, and psychological status before and after physical therapy treatment. The results showed an improvement in venous blood gases, arterial oxygenation saturation, mobility scale, activity level, anxiety, and depression scale. There have been few studies published on the effect of physical therapy on ECMO COVID-19 patients [10-12]. The patient is currently being managed according to the proposed modalities of exercise training established by Kourek C et al., (8).

Physical therapy is important for ECMO COVID-19 patients with severe respiratory diseases, which can severely affect peripheral tissues, leading to significant functional impairment. Early mobilisation and exercise in ECMO patients could prevent bedridden complications, enhance early recovery, and improve functional ability, mood, and psychological well-being. Physical therapy management may include therapeutic positioning, ROM exercises, progressive ambulation, and breathing exercises (7).

In ICU physical therapy plays a crucial role for patients who require support such as ventilation and MV (13). Critically ill patients may develop significant functional deficits and/or ICU-acquired weakness; therefore, mobilisation and exercise are recommended (14). Physiotherapy is an important strategy in the ICU for patients with COVID-19, as it prevents complications and improves their stability during critical periods, facilitating quicker recovery (15).

Early mobilisation is based on the aetiology of ECMO support. The upper-body cannulation approach is preferred when mobility is of sufficiently high priority for that patient (16). Additionally, the statement edited by Sommers J et al., on rehabilitation recommendations in ECMO patients suggests that rehabilitation management is primarily determined by the patient’s level of consciousness (17).

Similar to the case report by Mao L et al., for severe COVID-19 after bilateral lung transplantation, different techniques were used, including airway clearance, respiratory exercises, muscle strength exercises, transfer activities, and psychological support. Their results revealed that physical function, respiratory function, and activities of daily living improved for this patient after a thorough evaluation and early intervention from a multidisciplinary team (18). Additionally, the case report by Ibrahim AA et al., reported that COVID-19 patients with respiratory and physical problems benefit from physiotherapy expertise through telerehabilitation programs, which include intercostal muscle stretching, chest wall vibration, walking short distances, and breathing exercises. They assessed physical function, quality of life, depression, and anxiety (19).

In a case report by Lowman JD et al., a young female patient with severe respiratory failure due to cystic fibrosis and on ECMO received physical therapy treatment, including exercise, manual therapy, and airway clearance techniques. After eight days on ECMO, she successfully underwent a bilateral lung transplant (20).

Turner DA et al., (2011) presented two female cases with end-stage respiratory failure on ECMO awaiting lung transplantation. They received active rehabilitation while still on ECMO. After successful transplantation, the patients were weaned from mechanical ventilation and ECMO, transitioned out of the ICU, and became ambulatory in less than one week (21). In addition to respiratory and physical complaints, COVID-19 patients may feel neglected and depressed. Exercise therapy can help overcome stress and anxiety, allowing patients to return to their normal lives. Exercise therapy is essential for COVID-19 patients’ mental and physical health, helping them maintain physical fitness and independence (22).


The present case report suggests that early physical therapy and mobilisation in ECMO patients with COVID-19 infection is effective, safe, and helpful in decreasing bedridden complications and improving lung aeration. Future studies are needed to further evaluate the long-term outcomes of ECMO patients and to explore the risk factors for these individuals.


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DOI and Others

DOI: 10.7860/JCDR/2023/64508.18648

Date of Submission: Apr 05, 2023
Date of Peer Review: Jul 14, 2023
Date of Acceptance: Sep 05, 2023
Date of Publishing: Nov 01, 2023

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

• Plagiarism X-checker: Apr 09, 2023
• Manual Googling: Jul 19, 2023
• iThenticate Software: Sep 02, 2023 (10%)

ETYMOLOGY: Author Origin


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