PHOTO CAPTION: A physical therapist assists a patient in a balancing exercise. Physical deconditioning is common post-hospitalization among patients affected by longstanding or debilitating disorders. Aerobic exercise and strength training can help decrease risk of falls and improve overall fitness for this population.

By Erin Holland, PT, DPT, OCS, and Shirish Sachdeva, PT, DPT, MS, PGD-PPHC, FOR, BPT

The COVID-19 pandemic is leaving few people untouched by its effects. Whether you contract the virus or not, many people have experienced physical, mental, emotional, and other changes in their day-to-day lives due to the world’s response to slowing the spread of the virus, thus impacting their overall wellness. While the spotlight is currently turned on doctors and nurses—and rightly so—physical therapists are also essential workers, helping people manage their health during the pandemic. From helping prevent hospitalization to rehabilitating patients on ventilators, physical therapists have been utilizing their extensive movement and exercise science knowledge to provide comprehensive treatment plans to treat a variety of conditions and improve their patients’ quality of life.

Benefits of Physical Therapy

Physical therapy is known to impact the well-being of patients through expert quality care. A study in the Journal of the American College of Cardiology published a randomized controlled trial in 2019 about the impact of a 10-year exercise training in patients with chronic heart failure,1 concluding that “moderate supervised Exercise Therapy performed twice weekly for 10 years maintains functional capacity of more than 60% of maximum VO2 and confers a sustained improvement in quality of life compared with NT patients.” These results were also connected with a decrease in associated hospitalizations and mortality rates.

As well, studies show that physical therapy is a faster, more convenient way to treat pain, allowing patients to achieve optimal fitness and wellness sooner than other forms of treatment. A study in the Journal of Orthopedic & Sports Physical Therapy2 found 68% of patients with direct access to physical therapy had resolved symptoms without further medical treatment. Other studies, including a May 2018 study published in Health Services Research,3 have shown that PT lowers the probability of needing an opioid prescription, imaging services, and ER visits.

Further, engaging in physical therapy has mental health benefits for patients. Therapists often see patients show improved mental health standardized scores and report improved physical and mental health as their condition improved with physical therapy, while a cross-sectional study revealed exercise decreases people’s likelihood of poor mental health days.4

Therapists use patient-specific therapeutic exercises to improve an individual’s overall independence. Improvement in tasks associated with activities of daily living can positively affect a patient’s confidence.

Alleviating the Burden

In addition to the physical and mental health benefits, physical therapy also has logistical value during the pandemic. At a time when hospitals and doctors’ offices are at their maximum capacity, physical therapy is mitigating ER and MD visits by treating chronic pain conditions. Treatment of regular musculoskeletal issues such as back, neck, and knee pain as well as arthritic conditions are common. Taking on patients who would otherwise go to a hospital or ER for their pain or injuries helps allow hospitals to allocate more resources to caring for COVID patients. As well, physical therapy has helped surgery patients manage their conditions when hospitals postponed elective surgeries proactively to reduce the burden of care on the hospitals and improve care for COVID-19 patients. In this time, physical therapists stepped up their game to provide excellent care to patients and allow physicians to focus on COVID.

Preventing Injury and Hospitalization

Therapists have not just assisted in rehabbing pain and injuries, but have also worked with patients to prevent injuries during the pandemic, once again helping to avoid hospitalization. In particular, seniors have benefited from in-person and/or virtual physical therapy appointments that provide overall wellness and strength training to ensure proper execution of activities of daily living (ADLs) and help mitigate the risk of falls. Falls are a direct indicator of increased hospital stay, whether people get injured or not during the fall.5 One systematic review6 showed physical activity can assist in decreasing older adults’ risks for falls with balance measures improving 16-42% between studies when exercise therapy was utilized.

Balance-pads from AIREX, Somersworth, NH, and Wobble/Rockerboards by TheraBand, Akron, Ohio, are effective tools utilized in balance training, particularly in assisting with reactive balance. Aerobic exercise and strength training with free weights or resistance bands by TheraBand are also helpful in preventive care to decrease the risk for falls and improve overall fitness and wellness. Another source for these types of tools is Stretchwell, Warminster, Pa, which offers its line of Fit-Lastic Therapy Products that include bands, tubing, loops and straps made of natural rubber latex. Exertools, Petaluma, Calif, also offers a complete line of elastic bands, loops, and tubing manufactured in a range of resistance levels and colors for the physical therapy market.

Product Resources

These companies provide products and equipment that can be used to promote general fitness and wellness:

AlterG
www.alterg.com

Biodex
www.biodex.com

BTE
www.btetech.com

Exertools
https://exertools.com

Fitter International
www.fitter1.com

Magister Corp
www.magistercorp.com

OPTP
www.optp.com

Performance Health
www.performancehealth.com

Perry Dynamics
www.perrydynamics.com

Sissel USA
www.sisselshop.com

Spirit Fitness
www.spiritfitness.com

Stretchwell
www.stretchwell.com

The Hygienic Corp
www.theraband.com

Thought Technology
http://thoughttechnology.com

VersaSlider
www.versaslider.com

Recovering from Hospitalization

Hospitalization for COVID has been a matter of contention for most of the year. Due to the virus’s multi-system involvement, COVID patients with severe infections may experience a myriad of effects, including strokes, cardiovascular impact, and pulmonary symptoms. Physical deconditioning is a common side effect seen post-hospitalization in patients with longstanding or debilitating disorders.7 Luckily, this is another space in which physical therapy helps. One study found that early intervention8 of physical therapy and occupational services provided better outcomes for patients on ventilators, while a systemic review of physical therapy interventions for patients in the ICU9 found an improvement in overall quality of life, decreased amount of days on a ventilator, and shorter hospital stays. Physical and occupational therapists are often involved early after patients have been placed on mechanical ventilators to assist with active range of motion tasks and gentle strengthening to slow down patient deconditioning.

Physical therapy is known to help patients recover from other respiratory illnesses. A randomized control trial published in Clinical Rehabilitation Journal in 2019 about hospitalized pneumonia patients compared standard treatment only and standard treatment with physical therapy and electrical stimulation. The study concluded that the group who received physical therapy and electrical stimulation had better scores on short physical performance battery chair stand test. These patients also had better relief with cough and fatigue symptoms as compared to the control group.10

As patients wean off ventilators and improve their ability to perform daily needs such as completing transfers with less assistance and ambulating short distances, therapists begin to focus on increasing independence to allow for greater ease with ADLs and, in some cases, prepare patients to transition to rehab facilities or skilled nursing homes. Here, patients may be treated using a plethora of activity-specific rehabilitation to allow for greater ease with activities of daily living and continued strength training. Upper extremity bicycles can be useful in endurance training for upper body strengthening and endurance, while recumbent bicycles, treadmills and NuStep machines may be utilized to address lower extremity weakness and endurance training. Utilization of harness-based balance training systems can also be a great way to improve someone’s control while performing gait training. This allows for an extra level of safety compared to traditional systems of balance training. Technologies for this type of gait training are available from several manufacturers and include the ZeroG Gait and Balance System from Aretech, Ashburn, Va; SafeGait 360 Balance & Mobility Trainer from Gorbel Rehabilitation, Victor, NY; and Vector from Bioness, Valencia, Calif.

Therapists also utilize patient-specific therapeutic exercises to allow for greater ease with walking, increase balance, and improve overall independence with bathing, dressing, bed mobility, and more depending on the patient’s specific presentation. Improvement in someone’s control over tasks like walking really affects their confidence and approach toward life.

Long-Term Outlooks

The implications of longstanding hospitalization on patients may include serious effects such as increased risk of mental health issues like anxiety and depression with decline in mental abilities (seen more in elderly population). Anecdotally, therapists are noticing mental health improvements in COVID patients as they recover and prepare for discharge, since physical therapy actively improves their daily function and overall quality of life. It also provides patients with some social contact and an activity to look forward to, thereby helping to improve mental health.

Physical therapy also plays a strong role in the transition process from a hospital post-discharge into a healthy life. Patients who are admitted to hospitals and nursing homes during the pandemic face an enormous challenge to remain healthy. The inclusion of growing technology and its outreach in healthcare is of great support to these patients with their existing traditional physical and occupational therapies. A 2019 study revealed the benefits of home-based virtual reality rehabilitation training post-hospitalization. The study focused on patients with stroke and suggested that the use of virtual reality systems can be more effective as they can be used according to the patient’s schedule providing better health and rehabilitation benefits toward functional improvement.11 Post-COVID virtual visits have come up as a new trend in the medical fraternity, and physical therapy is also not untouched in this regard.

Improving Fitness & Wellness

In conclusion, now more than ever physical therapists are improving physical health and quality of life while assisting in improving mental health as well. Whether working to wean patients from ventilators, rehabilitating patients after a hospital stay, or decreasing risk of falls and mitigating hospital stays, physical therapists are working to assist patients’ overall fitness and wellness, and navigate the various challenges they have faced during the pandemic. PTP

Erin Holland, PT, DPT, OCS, is a physical therapist at ATI Physical Therapy. Erin is board-specialized in orthopedics and a clinical director in Chicago. She enjoys treating a variety of orthopedic injuries with a special interest in treating athletes. A graduate of the Saint Louis University, Erin has been practicing since 2016.

Shirish Sachdeva, PT, DPT, MS, PGD-PPHC, FOR, BPT, is a clinic director at ATI Physical Therapy specializing in orthopedic rehabilitation. Since beginning practicing in 2009, he has practiced in India and the United States. Shirish graduated from University of Pittsburgh with masters and Utica College with a doctorate in physical therapy. For more information, contact PTPEditor@medqor.com.

References

  1. Belardinelli R, Georgiou D, Cianci G, Purcaro A. 10-year exercise training in chronic heart failure: a randomized controlled trial. J Am Coll Cardiol. 2012 October;60(16);1521-1528. DOI: 10.1016/j.jacc.2012.06.036
  2. Denninger TR, Cook CE, Chapman CG, McHenry T, Thigpen CA. The influence of patient choice of first provider on costs and outcomes: analysis from a physical therapy patient registry. J Orthop Sports Phys Ther. 2018;48(2):63-71. DOI: 10.2519/jospt.2018.7423
  3. Frogner BK, Harwood K, Holly C Holly A Andrilla, Schwartz M, Pines JM. Physical therapy as the first point of care to treat low back pain: An instrumental variables approach to estimate impact on opioid prescription, health care utilization, and costs. Health Serv Res. 2018 May 23;53(6):4629-4646. DOI: 10.1111/1475-6773.12984
  4. Chekroud SR, Gueorguieva R, Zheutlin AB, et al. Association between physical exercise and mental health in 1·2 million individuals in the USA between 2011 and 2015: a cross-sectional study. Lancet Psychiatry. 2018; 5(9):739-746. DOI: 10.1016/S2215-0366(18)30227-X
  5. Dunne TJ, Gaboury I, Ashe MC. Falls in hospital increase length of stay regardless of degree of harm. J Eval in Clin Pract. 2014 May 9;20(4):396-400. DOI: 10.1111/jep.12144
  6. Thomas E, Battaglia G, Patti A, et al. Physical activity programs for balance and fall prevention in elderly: a systematic review. Medicine (Baltimore). 2019 July;98(27):e16218. DOI: 10.1097/MD.0000000000016218
  7. Felten-Barentsz KM, van Oorsouw R, Klooster E, et al. Recommendations for hospital-based physical therapists managing patients with COVID-19. Phys Ther. 2020 Aug 31;100(9):1444-1457. DOI: 10.1093/ptj/pzaa114
  8. Pohlman MC, Schweickert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010;38(11):2089-2094. DOI: 10.1097/CCM.0b013e3181f270c3
  9. Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013;41(6):1543-1554. DOI: 10.1097/CCM.0b013e31827ca637
  10. López-López L, Torres-Sánchez I, Rodríguez-Torres J, et al. Does adding an integrated physical therapy and neuromuscular electrical stimulation therapy to standard rehabilitation improve functional outcome in elderly patients with pneumonia? A randomised controlled trial. Clin Rehabil. 2019;33(11):1757-1766. DOI: 10.1177/0269215519859930
  11. Sheehy L, Taillon-Hobson A, Sveistrup H, et al. Home-based virtual reality training after discharge from hospital-based stroke rehabilitation: a parallel randomized feasibility trial. Trials. 2019 June 7; 20(1):333. 2019 Jun 7. DOI: 10.1186/s13063-019-3438-9