I first became interested in the Solstice Scholarship when Stephen Leppard and his team came to speak to my Western Michigan University DPT class of second-year students during one of our professionalism classes. They spoke about this exciting opportunity that has been offered at other DPT programs including the University of Michigan-Flint and Grand Valley State University and would now be expanded to Western Michigan University DPT students as well. The history of the scholarship started with the Solstice team racing ultra-marathons and using funds raised to pay for the college degree of their patient with spastic quadriplegic cerebral palsy.  Then, they began racing with their patient/friend Josh pushing him in marathons in a racing wheelchair!  The Solstice group was then asking the question "How can we give 'this' to others?  How can we facilitate this feeling, this community impact, this opportunity for PT students?"  So, the Solstice Scholarship was born.  Now, the group has annual scholarships for PT student community impact projects at Grand Valley State University, University of Michigan-Flint, and Western Michigan University.  Their story of lifting others up in the community through physical activity was so inspiring to me. I do not know anyone that could hear this group speak and not want to act immediately! The compassion that this group has for others, for their patients, and for the community is a beautiful model to all of us as future clinicians in how to treat others with respect and kindness and truly the art of advocating for what is right.

As they were speaking to my cohort, the wheels immediately started turning in my brain and I felt drawn to participate. In my undergraduate years, I had so many wonderful opportunities to support the Ypsilanti community through various student organizations at Eastern Michigan University and these were some of the most rewarding years of my life. The growth I experienced through these moments was significant in my college years and led me to want to pursue the Solstice Scholarship in my graduate school years.

I knew immediately the cause that I wanted to support... it was just a matter of putting all of the pieces together! I have a heart for those battling substance abuse and have for many years. As a child, a family member of mine was dealing with addiction, and it was very troubling for me to understand at such an early age. This situation caused a deep divide within my immediate family and left irreparable damage in its wake. As a young child, there were many emotions that I went through processing this situation, but I remember being very confused. This was an impactful part of my childhood and from that moment on I have always made it a point to seek out opportunities that would allow me to lift those currently struggling or those that have overcome substance abuse. After researching centers in the area, I chose to support Community Healing Centers of Kalamazoo.  After visiting them in person and meeting with the staff I knew immediately I had made the correct choice.

Also, personally, I have developed a big interest in rock climbing. What started as an activity that my boyfriend and I could do together turned into a passion of mine.  I really enjoy both the mental and physical challenges that climbing provides.  As soon as I left class the day the Solstice Scholarship group came in, I immediately reached out to Climb Kalamazoo to see if they would be willing to host an event at their facility and they were just as excited as I was at this opportunity! I thought this would be a beautiful blending of these two worlds, especially with rebuilding and maintaining familial relationships. I know from experience traditional family counseling is not for everyone, but I thought that having families lift each other up physically and verbally through encouragement while climbing might be beneficial and impactful on those relationships that might be in a tough spot.

The planning and fundraising process for this event has been rewarding and I will really miss getting to put things together each day. In keeping with the spirit of community, I reached out to many local Kalamazoo businesses for our raffle at the event. The entire DPT program at Western Michigan University also deserves a massive shoutout as I started a month-long penny war to fundraise for the event.  The competition was fierce between the cohorts and faculty members.  I feel so grateful to them that they participated and supported this event so strongly.

This event will be held on January 21st from 12:30-3 at Climb Kalamazoo. Participants will have the ability to learn to climb up the routes, learn to belay and tie knots, as well as the opportunity to support others that may be going through similar situations.

I am forever grateful to the Solstice Scholarship group for choosing me to support the Community Healing Center of Kalamazoo and for entrusting me as their first recipient of this scholarship from Western Michigan University. I cannot wait for the event to 'lift others up'!

Chloe Catallo is a 2nd year DPT student at Western Michigan University and is interested in working in Pediatrics upon graduation. She enjoys reading and spending time in the kitchen when she is not studying.

New devices and modalities seem to make their way into the physical therapy world with fanfare. As clinicians we want to do the best for our patients and sometimes the amount of treatment options can be overwhelming to wade through. Modalities, devices, and treatment options can be marketed quite aggressively, and this leaves the PT to sift through the data and testimonials to decode if it is a tool they would like to integrate into their practice or one that they can leave behind. If you have read through a lot of medical literature it can be frustrating to see the amount of treatments that have little to no effect on their own. It can be rare that a significant body of research exists in support of actual positive changes from a specific intervention. So, when something is presented that has clear evidence to support its benefits for patients it is very exciting and should challenge us to integrate it in our practice! I think that exercising under blood flow restriction is likely going to be the most beneficial “new” clinical treatment modality to become widespread in the lifespan of my clinical practice. I say new in quotations because there was experimentation with this starting in the late 1960/early 1970s by Dr. Yoshiaki Sato, but it has taken several years to become more widespread.

The research shows clear physiological improvements from exercises at 15-30% 1 RM under blood flow restriction. These improvements include: increase in aerobic capacity and VO2 max, higher level motor unit recruitment, increase in strength and force development, increase in hypertrophy, decrease in myostatin, increase in growth hormone as well as other benefits.  There are varying protocols, but generally, exercising with blood flow restricted should occur at least 2x/week for several weeks. There is also an importance placed on dosage. High repetitions to failure should be used with short rest periods in between sets. I usually use the 4 set scheme of 30 reps followed by 3 sets of 15. If the patient can reach these reps without failure the load should be increased.

When I first was trained in Blood Flow Restriction therapy it was not very widespread in Michigan. I traveled out to Colorado to train under Owen’s Recovery Science who uses the Delfi unit (the most expensive- but very high quality - option I am aware of for blood flow restriction therapy). In the last few years I have seen several companies begin to offer training courses (including on-line options) as well as growth in the actual tourniquet options.   More and more clinics are utilizing blood flow restriction now as well.

Each cuff or tourniquet is not created equal. As a medical professional I think that being objective in the pressure we are using is of utmost importance. Our commitment to safety limits the field of options in some sense as to which device you should use to occlude blood flow. I think it is important that no matter what cuff you are using you first find the limb occlusion pressure so that the prescription for exercise is personalized, specific, safe, and at a level that allows the gains mentioned earlier. There are machines that will calculate the limb occlusion pressure for you. Some of these are Smart Cuffs 3.0 and 4.0, the Delfi unit, and AirBands.  When automatic calculation is not an option, you can use a Doppler at the distal limb while inflating a cuff to find the limb occlusion pressure. The limb occlusion pressure is the starting point to determine the level of occlusion used while performing exercise. Wider cuffs require less pressure so they tend to be more comfortable. I also like a cuff that inflates evenly throughout. There are some cuffs that only inflate a portion of the cuff or have pockets of inflation. The Delfi unit probably has the most comfortable cuff on the market, but if you do not want to spend that much money, there are also other good options like Smart Cuffs. There are some machines that also auto regulate during an exercise to maintain a pressure close to the set pressure. Muscle contraction places more pressure against the cuff so the auto regulate mode tries to accommodate for this, which can make it more comfortable. The Delfi unit and Smart Cuffs 3.0 both have this option. There are models that have the pump built into the cuff for wireless use as well (AirBands and Smart cuffs 4.0).

The population I primarily work with are athletes, including several post-op diagnoses. There are specific benefits to lifting heavy, however, when an athlete is physically not able to do that safely, blood flow restriction therapy is a great option. The cuff restricts blood flow at a certain percentage and in this oxygen depleted environment the body switches over to Type II muscle fiber work, lactate builds up in the muscles and growth hormone production increases which are likely part of the mechanism leading to muscle hypertrophy and strength gains. The athletic population is not the only population that will see benefit from blood flow restriction therapy. The older or aging population can see great benefits from exercising under blood flow restriction as well. However, extra care needs to be taken with precautions/contraindications in this population. Research has shown that a walking program combined with blood flow restriction can increase strength and function as tested in the Timed up and Go.

There are some people who just do not tolerate the pressure well, but for the most part patients tolerate this okay. It is not a comfortable experience though! It is good to remind patients that it is normal to see the leg turning purple and feeling very tired. Warning signs would be nerve pain under the cuff or distal to the cuff as we want to make sure we are not causing damage to any nerves.

Ultimately, if you work with the orthopedic population I think this is an important tool to have in your tool bag. The amount of positive research should make this not a question of if you integrate it into your practice but how and when and what equipment, always first taking into account your patient’s safety.

Dr. VanZegeren is the Director of the Sports Academy at The Center for Physical Rehabilitation in Grand Rapids. She was certified in Blood Flow Restriction Therapy through Owens Recovery Science and has been using BFR since 2018. Rebekah earned her Doctorate in Physical Therapy from GVSU. She has participated as a volunteer medical provider at the Olympic Training Center in Colorado Springs as well as with the AVP.

Over three years have passed since the first COVID-19 infections were detected in Michigan. After several waves, the medical community has improved testing, treatment, and mitigation of acute infections. Long-term complications of the disease continue to be felt by the medical community and, more importantly, patients themselves. Physical therapists are an important member of a Long COVID treatment team, however; many Long COVID patients respond poorly to typical PT programs of increasing activity and exercise. Physical therapists must be aware of the unique requirements of patients within this population in order to become effective at managing the symptoms of Long COVID.

I found myself acutely ill with COVID-19 in March of 2020 with little information given the novelty and uncertainty surrounding the virus. Being young, active, and relatively healthy, I imagined the illness would be short-lived even though it had been the most sick I had felt in my adult life and included a few hours in observation at the hospital for intractable fever and unstable vitals. High fevers, coughing, shortness of breath, and aches tormented me for over two weeks until my condition began to improve. I began to resume my daily activities and exercise thinking the worst was over. Little did I know that the road ahead would be long, winding, and difficult.

Running was my choice of exercise. 5K, 10K, half-marathons - I had run them all and loved every second. I was eager to return to training through light jogging with the goal of an upcoming 5K that would later be canceled due to the fall surge of COVID-19 cases. What was previously easy for me - a mile jog - had become tortuous. This seemingly simple activity would leave me bed bound for the rest of the day and often the next. I was not used to this feeling, but figured it was a normal part of recovering from illness. Given my training as a physical therapist, I had set goals on increasing my activity little by little. After months of pushing and getting nowhere, I began to wonder if I would ever recover from this setback.

Frustrated and looking for answers, I did what anyone with a smartphone and time on their hands does - turned to the internet. It was through online channels that I found others experiencing the same thing. People who were not getting better after becoming ill. People who were previously active and pushing through their symptoms. People looking for answers on what was going on inside their formerly healthy bodies. Brought together by a common skillset, I found myself chatting with other physical therapists around the world also dealing with this now-named problem - Long COVID. Thus was born Long COVID Physio, an international organization of healthcare professionals living with Long COVID and committed to providing research and education to rehab professionals and patients. We learned that pushing and increasing activity was not the answer. Perhaps the solution was found in a much older form of convalescence - rest.

Post-viral illness is not a new phenomenon, though it may be unfamiliar to those in the physical therapy field. Myalgic Encephalomyelitis, sometimes called Chronic Fatigue Syndrome or ME/CFS, may be caused by inflammation in neural cells and dysfunction in cellular energy metabolism and ion transport. This is often preceded by a viral infection, and the hallmark symptom of this disease is post-exertional malaise (PEM) or, more recently, post-exertional symptom exacerbation (PESE).1 PEM/PESE is defined as a worsening of symptoms that follows an activity that was previously tolerated without symptoms. These activities can be physical, cognitive, social or emotional. Symptoms will generally occur 12-48 hours after the activity and can last for days or weeks but is variable within and between people2. Many patients with Long COVID also experience this symptom, and the overlap with ME/CFS can help guide physical therapy treatment for Long COVID.

Symptoms of Long COVID are many and cover the gamut of body systems. Patients have reported over 200 unique symptoms across 10 organ systems3. Physical Therapists may be asked to treat a variety of familiar symptoms including shortness of breath, headache, dizziness, neuropathies, and joint pain. Additionally, clinicians will likely see patients with the most common symptom of Long COVID - fatigue.3 Fatigue experienced by patients living with Long COVID is unlike traditional experiences in that it is extreme and debilitating in nature and is not easily relieved with sleep. This symptom often limits daily function and has a negative impact on quality of life.

The first instinct of a Physical Therapist with this patient in front of them may be to provide activity recommendations and slowly increase the regimen as the plan of care progresses. There are several factors that should be considered, however; given our knowledge on the disease process. The World Physiotherapy organization along with many other institutions (including the American Physical Therapy Association, APTA) have provided a document including recommendations for treating patients with Long COVID that can be found as reference number two in this article. In this document, there are four screening tools that should be used before prescribing exercise or physical activity to a patient with confirmed or suspected Long COVID. These include screening for PEM/PESE, cardiac impairments, exertional oxygen desaturation, and autonomic nervous system dysfunction2. These cautions are echoed in the World Health Organization (WHO) guidelines for Clinical Management of COVID-19 listing these same screens as red flags for safe rehabilitation4. A positive finding in one of these areas does not exclude a patient from physical therapy treatment; however, care must be taken to ensure that treatment does not cause a worsening of symptoms for the patient.

Understanding post-exertional malaise or symptom exacerbation may be new for many physical therapists. The initial assessment for PEM/PESE can be done subjectively. Common descriptors of this symptom may include extreme fatigue or exhaustion, heaviness of the limbs or body, confusion or “brain fog,” or feeling drained. Some patients will refer to PEM/PESE as a “relapse” or a “crash.” If an objective tool is required or appropriate the Depaul Symptom Questionnaire may be appropriate for some patients.5 Patients may not realize that the fatigue they are feeling is actually PEM/PESE, and it may be the clinician who first clues them into this symptom. In patients presenting with PEM/PESE, graded exercise therapy, that is, an approach prescribed by clinicians based on fixed incremental increases in physical activity or exercise, is contraindicated.  Instead, a symptom-contingent pacing strategy is more appropriate to ensure patient safety and satisfaction.

A Physical Therapist is likely familiar with pacing strategies as they are often used in patients with cardiac conditions, those in post-concussion protocols, and in cases of overtraining. The unexpected part of pacing in instances of Long COVID is often how quickly and easily PEM/PESE can be triggered with even the lightest amounts of activity. Research in ME/CFS populations with the use of 2-day cardiopulmonary exercise testing has sought a mechanism in understanding post-viral fatigue. One significant difference between control and study groups is when patients reach their ventilatory/anaerobic threshold - that is the point at which lactic acid begins to accumulate faster than it can be cleared, making sustained activity difficult. Studies found that ME/CFS patients were reaching this threshold at heart rates as low as 65 bpm while performing activities as light as 2-3 METs.7 For reference, that level of activity is equivalent to reading, getting dressed, or walking slowly on level ground. With that in mind, it is no surprise that a patient may experience PEM/PESE while exercising, completing housework, or working at a job.

Some therapists may be scratching their head at this point – I need to treat this patient in front of me, but getting dressed is enough to exacerbate their symptoms. How will I prescribe an appropriate exercise program? Exercise is a great tool that therapists use for a variety of conditions, but it is just a piece of our wide scope of practice. The aforementioned WHO guidelines on management COVID-19 confirm that PTs can be useful beyond our training in exercise. They suggest education and skills training on energy conservation as a practical approach to treating patients with Long COVID. They continue that training the use of assistive devices and providing environmental modifications are also appropriate for those with PEM/PESE.4 By adding these different interventions into our plan of care, we can continue to treat the patient without causing harm through symptom exacerbation.

There are many strategies that are useful when initiating a pacing program with a patient, however; the most important aspect is that the program be individualized and patient-centered. Several analogies exist to facilitate a patient’s understanding of their pacing program. A therapist should help guide the patient to determine what analogy and program works best for them. One such analogy, known as the Energy Envelope Theory, states that by maintaining energy expenditure within the level of perceived available energy, patients will be able to improve physical and mental function and reduce symptom severity and frequency/duration of relapse.6  The theory suggests that patients should only complete activities that they can safely manage without symptom exacerbation, and that by avoiding symptom exacerbation, patients may actually be able to expand their energy envelope and therefore increase their activity levels. On the flip side, symptom exacerbation may actually shrink the energy envelope and cause further activity limitations. Another common analogy is the Spoon Theory which states that patients with energy-limiting conditions have a limited supply of energy which are their “spoons.” Activities cost a varying number of spoons and patients can use this analogy to determine an activity plan for the day. Regardless of the analogy used, the strategy remains the same - avoid symptom exacerbation and strive for symptom stabilization through pacing and rest.

As previously stated, implementing a pacing program should be individualized and patient-centered, but a few basic principles can aid in creating a plan. One of the first steps in establishing this plan should be to determine a baseline - what is the patient able to do without causing PEM/PESE. All activity and exercise should be maintained below this baseline. The therapist should encourage the patient to listen to their body and take breaks in activity even if symptoms are not present. This will ensure that the patient is not exceeding their anaerobic threshold and PEM/PESE will not be triggered. Increases in activity should only occur when the patient is stable and confident in moving forward. The increase should be small in nature and if symptoms occur, the patient should immediately return to the previously tolerated level of activity. When discussing this plan with the patient, it is important to prioritize activities. Ask the patient, “What needs to be done this week? What needs to be done today?.” The therapist can provide strategies that may include delegation, modification, or delaying of tasks. Create a routine that includes planned and meaningful rest breaks. Activity diaries can be helpful for some patients, but may drain the energy supply, so a therapist can assist the patient in completing these logs. Tolerance to activity can change day-to-day and week-to-week, so it is important to review the plan and make adjustments with the patient based on their current capacity.

There are some specific considerations that a Physical Therapist should keep in mind when working with patients with Long COVID. It is important to prioritize preferred activities over therapy sessions. Flexible cancellation and scheduling policies can help in this instance when the patient is unable to make it to a therapy session. Therapists should also utilize telehealth options when possible. A large amount of energy can be expended when preparing and traveling to an in-person therapy session which may leave little room for other activities. In many cases, the traditional therapy model may not be beneficial for this population. Consider a consultative model where the patient makes regular check-ins at less frequent intervals rather than seeing the patient weekly or more. Ensure that the patient is making the decision to increase activity levels by listening to their body rather than the therapist pushing the patient. The therapist should also consider the trauma that patients may have received from other healthcare professionals. By listening and believing the patient, physical therapists can create a more impactful therapeutic relationship that will hopefully allow the patient to trust their clinician and more easily progress toward goals.

My own personal Long COVID journey continues, but through lots of trial and error, I have continued to make meaningful gains in my activity tolerance and symptom management. My wins these days are not always in how many steps I took in a day or how many hours I was able to work that week. Sometimes, the wins come through advocating for accommodations for myself or recognizing my own limitations to avoid a setback. As physical therapists, we are in a great position to advocate for patient-centered care. Reframing our mindset beyond exercise prescription can be challenging, however; it is important in cases of energy-limiting conditions. By treating in the whole scope of practice, Physical Therapists can be effective and necessary members of a Long COVID treatment team.

If you would like more resources on how to effectively treat patients living with Long COVID, there are many free resources available at www.longcovid.physio.

Ted DeChane is a pediatric physical therapist practicing in Port Huron, Michigan. He is a founding member of Long COVID Physio and previously served as the communications chair for the international  organization focused on advocating for patient safety and clinician education. Ted is currently involved in APTA Michigan as the communications chair for the Pediatrics Special Interest Group.

References:

1. Carruthers BM, van de Sande MI, De Meirleir KL, Klimas NG, Broderick G, Mitchell T, et al. Myalgic encephalomyelitis: International Consensus Criteria. J Intern Med. 2011;270(4):327-38. https://www.ncbi.nlm.nih.gov/pubmed/21777306.
2. World Physiotherapy. World Physiotherapy Response to COVID-19 Briefing Paper 9. Safe rehabilitation approaches for people living with Long COVID: physical activity and exercise. London, UK: World Physiotherapy; 2021.
3. Davis H, Assaf G, McCorkell L, Wei H, Low R, Re'em Y, et al. Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact. medRxiv. 2020. https://www.medrxiv.org/content/10.1101/2020.12.24.20248802v2.
4. Clinical management of COVID-19: living guideline, 18 August 2023. Geneva: World Health Organization; 2023 (WHO/2019-nCoV/Clinical/2022.2). Licence: CC BY-NC-SA 3.0 IGO.
5. Cotler J, Holtzman C, Dudun C, Jason LA. A Brief Questionnaire to Assess Post-Exertional Malaise. Diagnostics (Basel). 2018;8(3):66. https://www.ncbi.nlm.nih.gov/pubmed/30208578.
6. Jason LA, Brown M, Brown A, Evans M, Flores S, Grant-Holler E, et al. Energy Conservation/Envelope Theory Interventions to Help Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Fatigue. 2013;1(1-2):27-42.
7. Ella, A. (2019, January 17). Decoding the 2-day Cardiopulmonary Exercise Test (CPET) in Chronic Fatigue Syndrome (ME/CFS) [web log]. Retrieved September 26, 2021, from https://www.healthrising.org/blog/2019/01/17/decoding-2-day-cpet-chronic-fatigue-syndrome/.