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.

 

 

Burnout is a syndrome resulting from workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion, increased mental distance from one’s job, and reduced professional efficacy (World Health Organization, 2019). Some occupations are more vulnerable than others to the effects of burnout, with teachers and health care workers experiencing some of the highest rates of burnout even pre-pandemic (Abramson, 2022). There is currently a group on Facebook with 41K+ rehab professionals looking to get out of patient care and the overwhelming majority state burnout as the reason.

Since the start of the pandemic, employee well-being has been a greater topic of discussion and research within the Fortune 500 companies. Prior, the responsibility was on the employee to reduce their level of stress by using mindfulness, meditation apps, or taking advantage of health coverage for therapy. That trend is changing and organizations are acknowledging the important connection between workplace conditions and well–being. (Stringer, 2023). But, is this trend taking place in the rehab world yet? While some rehab companies and hospitals may be focusing on employee well-being, it seems the overwhelming majority are not.

Physical therapists often find themselves working in positions where productivity requirements are unrealistic across all settings. They are spending many hours outside of work completing documentation and catching up on other tasks. For those who have taken on leadership roles, many are completing administrative duties outside of patient care on their own time. When you factor in the unpaid overtime to catch up, people are often making lower salaries than they anticipated. If we also factor in the rising cost of education, changing and diminishing reimbursement, and the lack of career growth – it all seems pretty grim.

No wonder burnout is at an all time high. About 22,000 physical therapists left the healthcare workforce in 2021. The Bureau of Labor Statistics predicts about 15,400 openings for physical therapists each year, on average, over the next decade, resulting from those transferring to different occupations or exiting the labor force (APTQI, 2022). So what should we do about it? Throw a pizza party! Just kidding, we need policy and structural change. So how do we do that? Here is our shameless plug to join a professional organization, such as the American Physical Therapy Organization (APTA). They provide a consistent lobby presence with members of Congress, regulatory agencies, and commercial payers. Joining the association, volunteering, and adding your voice strengthens our efforts. You can check out what the APTA has already done this year by going to: https://www.apta.org/article/2023/06/14/advocacy-roundup

While policy change can move slowly, there are things that you can do in the meantime to help reduce the impact of burnout. Back in 2019 we did a presentation at the APTA Michigan Fall Conference on the topic of burnout in physical therapy. The two of us shared our perspective of being younger therapists in the field,  along with a more seasoned therapist, Karen Frederick. At times, going to work seemed hard and we each felt that we were lacking that initial passion that we came into the profession with. Real change is more often spurred by desperation than inspiration (Turak, 2014).

From our experience, most physical therapists that we know are not experiencing burn out because they just don’t care anymore. In fact, it seems to be the opposite. Many of them tend to care too much. They lose focus of what really matters to them. They overextend themselves to see too many patients per week by trying to meet unrealistic productivity standards. They are giving up their lunches to see patients or tacking a few on to the end of their work day. They don’t want to document during a treatment for fear of not being able to provide a patient their full undivided attention. They feel trapped in jobs that they hate because they feel loyal to their companies and current patients, despite companies having no loyalty to them. They try to be the best at what they do and sign up for as many continuing education classes as they can. While some of these things are not bad to do in moderation, ultimately there is no way that anyone can continue to function this way long term.

 

Here are a few strategies you can start implementing:

-Reach out to your clinic owner/manager

Discuss what can be done to make the current situation better

Have clear expectations on what your job entails

-Increase efficiency

Point of service documentation

Creating templates and smart phrases that you can access quickly

Only handle documents, emails, etc. one time

Prioritize your to do list and stick to it

Check your email at select times of the day if possible

-Focus on bringing positivity to your workplace

            Team building activities

            Get to know your co-workers

-Take time off of work

            Plan a relaxing vacation or a day off to spend time at home catching up on life

-Switch up your work

Try out a new schedule at your current job

Decrease work hours if needed

Take on a new role that excites you

Step down from a role that you feel you cannot fulfill or delegate appropriate tasks to others 

-Set boundaries with yourself and with your patients

Realize that when you say yes to one thing, you are ultimately saying no to something else

Do not constantly overextend yourself

Commit to what really matters

-Take advantage of mental health resources offered by many large workplaces and the APTA

https://www.apta.org/article/2023/05/22/mental-health-resources

Counseling services

Well-being webinars or support groups

Subscriptions to meditation apps

-Learn something new

Surround yourself with like-minded individuals while you gain a new skill at a continuing education course

Check out a new PT podcast

            Seek mentorship from another therapist - it doesn’t matter how long you have been

practicing, you can always learn something new

Read a book on burnout 

-Connect with others

Join the APTA            

Attend APTA Michigan conferences and district meetings to get to know others in your area

Join special interest groups, sections or academies of the APTA to find common ground

-Be a mentor

Mentor a new grad or serve as a clinical instructor for a student

Reignite your passion by spending time with someone who is very motivated about the profession and challenge yourself to be a better clinician

-Look into a different job

Take on a different role within your current company (ie. management, PRN coverage

staff, etc.)

Same setting, new company – sometimes you just need a fresh start

Try out a different setting (ie outpatient, inpatient, home health, school therapy etc.)

            Non-clinical jobs (ie insurance, medical sales rep for PT products, wellness coaching,

etc.)

-Look for solutions to decrease your workload at home

            Family member support

            Outsourcing tasks

-Find ways to refill your cup outside of work

            Hobbies

            Self-care routines

            Prioritize sleep, health and wellness

            Practice resilience strategies

            Volunteer to do something that makes you feel good – PT related or not

 

We still believe the ultimate solution is policy and structural change within all rehabilitation systems. Taking action at a macro or micro level is beneficial to driving overall change and reducing the effects of burnout.

 

Lauren is an alumni of the University of Michigan-Flint’s DPT program and has practiced physical

therapy on the lakeshore of West Michigan for over ten years. She has worked primarily in outpatient orthopedics, but has also worked in a school-based setting and in acute care. She has specialty training in osteopathic manual treatment, pelvic rehab, vestibular rehab, and aquatic therapy. Currently, she serves as a lab assistant for the Academy of Aquatic Physical Therapy. Lauren is passionate about involvement within the American Physical Therapy Association and decreasing burnout in the field of PT.

 

Niki has been practicing in outpatient orthopedics for the last 10 years. She is a board certified orthopedic clinical specialist and alumni of the University of Michigan Flint. She currently serves as clinical manager at Atheltico Physical Therapy in Detroit at the Renaissance Center.

 

References:

(2019, May 28). Burn-out an "occupational phenomenon": International Classification of Disease. World Health Organization. Retrieved September 29, 2023, from https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases

Abramson, A. (2022, January 1). Burnout and stress are everywhere. Monitor on Psychology, 53(01), 72. https://www.apa.org/monitor/2022/01/special-burnout-stress

Stringer, H. (2023, January 1). Worker well-being is in demand as organizational culture shifts. Monitor on Psychology, 54(01), 58. https://www.apa.org/monitor/2023/01/trends-worker-well-being

APTQI (2022, November 28). New Report Shows Thousands of Physical Therapists Left the Workforce in 2021. Alliance For Physical Therapy Quality and Innovation. Retrieved September 23, 2023, from https://www.aptqi.com/new-report-shows-thousands-of-physical-therapists-left-the-workforce-in-2021/

Roundup: Apta advocacy: Getting results. APTA. June 14, 2023. Accessed October 1, 2023. https://www.apta.org/article/2023/06/14/advocacy-roundup.

Turak, A. (2014, January 16). 3 keys to getting and staying inspired. Forbes. https://www.forbes.com/sites/augustturak/2011/09/09/3-keys-to-getting-and-staying-inspired/?sh=5c466e112628

Roundup: Mental health resources for physical therapy professionals. APTA. May 22, 2023. Accessed September 15, 2023. https://www.apta.org/article/2023/05/22/mental-health-resources

 

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.

 

 

 

Upon arrival in Washington D.C. I did not know what to expect, little did I know this event would alter my view of my professional career forever. Being surrounded by so much of our country's history I was able to reflect on how impactful the power of speech was in eliciting change.

I was encouraged that this event would be impactful to the future of physical therapy and could not have been more excited to play a part in that. Taking action towards something that meant so much to me as a SPTA felt invigorating and left me with a hopeful sense that if nothing else I would learn more about what it meant to be an advocate. Within the first five hours of being in Washington D.C., I was able to go to an open house at the APTA Centennial Center which allowed me to meet many professionals associated with APTA. My chapter president, Edward Mathis was incredibly helpful throughout this trip. He took it upon himself to introduce me to board members, professionals from a plethora of states, individuals who work in areas of my interest such as those involved in acute care, and many more. I was able to network with other students in my position as well as clinicians who are currently working within their states from all over the country. During this time of networking, I was able to engage in conversations regarding other committees I could join, student groups that were directly applicable to my current studies, as well as learning about job opportunities on the other side of the country. This was one of the most beneficial events in my student career thus far.

The time following this event was with the other students who represented other states. Each night the students were able to engage in social gatherings that allowed us to speak about board exams, clinical settings we enjoyed, testing tips, and residency opportunities. This time I found it to be helpful because it allowed me to learn about new avenues I could take as a student and other ways I could create change within my community.

The next evening, I was able to go to a Keynote Address. As a young student just starting my career, it was very interesting. The speaker addressed growth, both personally and professionally. He stated that to grow, we must continue a cycle of exploring new ideas and then exploiting one of the things we learned in the exploration phase. This struck me; I could apply much of this thought process to my personal and professional career. I have been applying this concept to much of my schooling since the keynote. I am currently exploring different therapy settings and deciding which setting I would like to explore and focus on.

The following day I was able to attend a Student Development Programming. I enjoyed this event because it allowed the student representatives to meet, interact, and begin to form connections. During this event, we learned about the House of Delegates, which included topics such as what the House of Delegates was, what a motion is and how a motion is passed, who gets to speak for each state, and much more. We were allotted time to view the House of Delegates debate on motions wanting to be passed. I felt that my eyes were opened to an important part of the physical therapy profession: advocacy. I was interested to see that after a motion was proposed individuals representing states were able to speak their opinion on the motion and give feedback to the House. Students were allowed to speak at that time, and it encouraged me that my voice does matter and advocacy could truly impact the profession that we all love.

Overall, this experience was one I would recommend to all students. This was something that helped me to build connections with clinicians and students nationwide, understand why my voice matters, and how to intentionally use my voice to promote a positive change. I will forever be grateful to the Michigan APTA chapter for supporting and encouraging me to take part in this fantastic opportunity.

 

My name is Kali Hall, I am a student at Baker College of Muskegon in the PTA program. I am my cohort's "class officer", the student state representative of Michigan, and a committee member of Michigan's PTA Engagement Committee. I have worked for the last six years at Mary Free Bed Rehabilitation Hospital as a Rehab Tech on the spinal cord injury unit. After graduation, I hope to work in an acute care setting with neuro patients.

 

 

 

 

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/.

 

 

The question was… How can we support leading PT students? Then, how can we support licensed physical therapists in Michigan that lead in the clinic AND in the community? How can we lift others up?

Our question all started with a canoe race. In 2008, a friend Brandon Gerardy (U of M DPT ’08) and I were racing the AuSable River Canoe Marathon. This is a 120 mile overnight canoe race in Northern Michigan that starts at 9pm in Grayling and ends in Oscoda the next afternoon. While preparing to race, I had a patient Josh who was born with spastic quadriplegic cerebral palsy who I was treating in PT. At the time, Josh was preparing to attend college at KVCC. We thought… What if we raise $1 per mile as we race and use the money to help Josh pay for college? Josh was preparing to pursue an Associate’s degree at KVCC with a concentration in Video Game Design. So, we started a “Paddling For Josh” fundraiser with our racing. Our 120 mile canoe race was successful and Josh began college. We were paying for his books, transportation, and tuition with donations. Then, from 2008 to 2017, Josh continued to attend KVCC all while we continued to race ultra-marathons paying for his college. Josh graduated with his Associates degree April 30th 2017. I would venture this is the first time in history that anyone has ever paid for a college degree with canoe racing! This whole process of helping Josh was a big compass point for us. We had intended to help him, but along the way we gained perspective. I had not anticipated that I would grow from helping Josh. Then, after Josh graduated in 2017, we thought “What if instead of racing FOR Josh, we start racing WITH Josh? So, with race support from myTEAM TRIUMPH, we pushed Josh in the Grand Rapids Half Marathon in 2017. Josh said this went ‘too fast’ and wanted to do a longer race. Funny right?!? So, then we raced the Riverbank 25K with Josh as our Captain. Then, Josh set his sights on a bigger goal… a full marathon with a goal of qualifying for the Boston Marathon. So, the next year, Josh raced a 4 hour, 19 minute full marathon with a single pusher and qualified for Boston as a Duo Team! With the pandemic, Boston offered Josh the opportunity to race virtually to earn his medal. So, the PT community and the running community in West Michigan came together as Josh raced to earn his Boston Marathon medal!

This whole process of helping Josh was a big compass point for us. Our group was sitting around a bonfire in Traverse City and said “How can we give this feeling to other people? How cool is it that we can help a patient outside of the clinic, pay for his college, help him race marathons, support him in life, AND we can grow along the way!?! How can we facilitate this growth and this feeling of helping others that we had with helping Josh?” As we brainstormed, we realized that we couldn’t necessarily ‘give’ this feeling to people. If we would not have canoed for Josh and raced with Josh, we wouldn’t have had the appreciation of the journey of helping him. I had graduated Grand Valley’s PT program in 2000, but it was not until 2008 that we did the canoe race and became active in the community. Why did I wait 8 years? How can we facilitate this community impact in students 8-10 years before I was active? PT students would tell us “I would love to help somebody, but I do not have any extra money. I want to help others, but I do not know where to get started”. There were seven families camping and we all decided to contribute $100 to start our own scholarship. Our plan was to create a $500 annual scholarship for a Grand Valley PT student for a community impact project. We worked with Dan Vaughn (the DPT Program Chair at the time) to establish our fledgling scholarship at GVSU. Our plan was to offer $500 annually to a GVSU DPT student over the next 25 years to help PT students at our alma mater make their own community impact. We hoped this would facilitate the life enrichment we had experienced helping Josh. We wanted to create a ‘nudge’ to help leaders in the next generation of physical therapists. So, my wife Ryane Leppard, Brandon and Emily Gerardy, Adam and Kristen Beadenkopf from Kentwood PT, Mark and Angie Scarlato, Cailee Bartow, Dan Vaughn, and I established our “Solstice Scholarship” at GVSU. We envisioned that we would run this as a pay as we go scholarship… each year we would contribute our own $500-700, support the community outreach of a leading PT student with $500, and repeat that for 25 years. This was the initial plan.

The first year that our GVSU Solstice Scholarship was awarded, we had a phenomenal winner. Our selected winner, Ally, had overcome an eating disorder herself. When she interviewed for our scholarship, she presented a plan to organize a NEDA Walk and give the $500 we awarded to the National Eating Disorders Association to help those who were overcoming eating disorders. Ally’s event was a success and she was supported by her GVSU classmates/professors. We only had a couple hundred dollars left, but were excited to have supported a leading PT student. Our group was already looking forward to the next GVSU cohort. Then, the positives in our PT profession, in our community, and in social media began to emerge. Our race efforts with Josh and Ally’s community action led to a swell of grassroots support from professors, therapists, and community members. A GVSU professor sent us a check for $100. We received $200 from someone in Portland. A family member of our group donated $500 to pay for one scholarship. Then, a friend Diane with MS said “I can’t run, but when I watch you run with Josh I feel like I’m running TOO (here’s a much larger donation)”! This ripple effect continued to the point that we were able to establish our own Solstice Foundation fund at the Kalamazoo Community Foundation. This is a managed fund that we can use to continually impact our PT profession and our community.

The following year in 2020, Dan Vaughn was preparing to retire as the GVSU DPT Department Chair. We were able to surprise Dan with a plan to establish the Vaughn Philanthropy Award in his honor. We would award $1,000 to a leading PT with a license in the State of Michigan. We hoped to support a PT that was active in the clinic AND in the community. Much like our Solstice Scholarship for DPT students, the Vaughn Award would allow a practicing PT to impact their own community. Our first Vaughn Philanthropy Award winner Tegan Roobol is a school system PT and an American Ninja Warrior. Per Tegan “The idea for Overcoming Obstacles Adaptive Ninja & Climbing started when I ran into one of my student’s sisters at the local ninja gym. I thought wouldn’t it be cool if she could experience the gym or participate somehow?” So, Tegan established her own 501c3 Overcoming Obstacles ‘To enrich and transform the lives of individuals with disabilities by providing them with opportunities to participate in adaptive sports in their community’. We were able to award Tegan the $1,000 to purchase equipment and to support her ninjas. In the legacy of Dan, she is giving others confidence in their own abilities. We plan to repeat this Vaughn Award every other year over the next 25 years.

The next year in 2021, we were able to expand our Solstice Scholarship to the University of Michigan. Two members of our foundation group had attended Michigan so this was the next logical step. We expanded our scholarship to Michigan with the same plan we had at GVSU. It was our plan to provide an annual scholarship to a deserving DPT student for 25 straight years. It was our idea to encourage 25 PT students to think outside of themselves while they are still in school. It was our goal to impact 25 local causes/organizations that the PT students select. It was our hope that these 25 different organizations then have immeasurable impacts in the community. Our first annual University of Michigan winners Kassidy and Ben both had the shared experience of losing a loved one to the tragedy of suicide. They wanted to work together to create an event that their family/friends/community could attend where they could realize that they are not alone and suicide is something that NEEDS to be talked about. Kassidy and Ben donated their $500 winnings to the Michigan Chapter of the American Foundation for Suicide Prevention and created a color run event on campus to support their family, friends, classmates, and community. Powerful. All the more impressive because they are second year DPT students creating this community activity! This is the exact purpose of our Solstice Scholarship… to support leaders in the next generation of PT and give them a boost while they are still in PT school.

Since our first GVSU winner in 2019, we have been able to support additional annual student community projects. In 2020, Lien Tran was able to run a ½ marathon in her brother’s memory and donate $500 to St Jude to thank them for the cancer care that her brother had received 20 years ago when she was four years old. In 2021, Hayley Hall donated her $500 to Miracle League in Grand Rapids and created a Miracle League Homerun Derby for local kids. In 2022, Katie Reed pushed her friend Savannah in a racing wheelchair in the SHE RUNS 5K and donated her $500 to myTEAM TRIUMPH. MTT is an athletic ride-along program created for children, teens, adults, and veterans who are disabled and would not normally be able to experience endurance events such as road races (also the same organization who we have raced with to support our man Josh!). Also, last year, our second Vaughn Philanthropy Award winner Amy Yorke, PT, PhD was awarded $1,000 for her plan to establish a Rock Steady Boxing program at U of M Heart to support Flint residents with Parkinson disease. Also, in 2022, our Solstice Scholarship was able to announce expansion to the DPT program at Western Michigan University for the next 10 years. Three of our foundation members live in Kalamazoo and I lecture annually for the WMU DPT program. So, once again, this was an organic expansion choice for our PT foundation.

Then, later in 2022, we were encouraged to submit an abstract for poster board consideration to the APTA Michigan Fall Conference. Our abstract titled “Transforming Society By Lifting Others Up: A Case Report on Philanthropy in Physical Therapy” was accepted to Fall Conference (and then later to Combined Sections in San Diego). So, this February 25th 2023, we presented our poster board at APTA CSM and won the Social Responsibility Award for the ‘Leadership & Innovation’ category at CSM! We were fortunate to be able to present at CSM, connect with many like-minded PT’s from across the Nation, and spread the word of what DPT students and licensed PT’s are achieving in Michigan.

This year, in 2023, we have been able to award our Fifth Annual Solstice Scholarship to Jordyn Bowman from the GVSU DPT program. Her plan was to donate her $500 to Guiding Light Mission in Grand Rapids. Her best friend lost her mother to substance abuse last summer. Jordyn was recently featured on the Guiding Light podcast, donated her winnings to Guiding Light to help those battling substance abuse regain their freedom, and will help support the Guiding Light 5K this October. Also, we were fortunate to be able to recently award our Second Annual University of Michigan Solstice Scholarship to Olivia Roe and Brooke Mazzolini. They both grew up playing sports and appreciate the ‘movement is medicine’ idea that our profession prides itself on. With the recent childhood obesity epidemic, they want to show kids that activity and movement can (and should) be fun. They plan to donate their $500 to Sylvester Broome Empowerment Village in Flint and create a field day for local kids. Then, this Fall, we look forward to interviewing our very first WMU DPT Solstice Scholarship cohort!

With all of this… Why “Solstice” Scholarship and Solstice Foundation? Well, originally, we were camping on the Summer Solstice as we brainstormed ‘How can we give this feeling to others?’. Also, synonyms for Solstice include elevation, rise, and turning point. We hope that the Solstice Scholarship can help serve as the elevation and the rise for future leaders to create their own ripple effect in our PT profession. We feel fortunate that from 2019 to 2023, we have grown from $0… to fully funded Solstice Scholarships with the GVSU/Michigan/WMU DPT programs, to the Vaughn Philanthropy Award for licensed PT’s, to our own Solstice Foundation fund for PT profession impact, to being recognized with the Social Responsibility Award at CSM… all from sitting around a bonfire on the Summer Solstice. We are flattered with the community support we have received for this PT advocacy and look forward to watching this outreach grow over the next 25 years. “Lifting Others Up” is central in our professional responsibility as physical therapists.

 

Stephen Leppard, PT, OMPT, CSCS is an outpatient, sports-medicine physical therapist in Kalamazoo. He graduated from the GVSU PT program in 2000 and completed his Residency Certificate in OMPT through Oakland University in 2005. Steve is the center manager at NovaCare Rehabilitation in Kalamazoo. He is the PT for Gazelle Sports and has practiced in the Kalamazoo community for the past 21 years. He enjoys running marathons/half-marathons with myTEAM TRIUMPH, canoeing, camping with friends, and hockey/soccer with their two boys. For more information please follow/message the Solstice Foundation, Solstice Scholarship, and Vaughn Philanthropy Award on Instagram and Facebook.

 

 

 

I am thrilled to be sharing Part 3 - my reflections on the future of Oncology Rehabilitation (Onc R).This three-part series for the APTA MI Lines blog has offered everyone a journey through the past or history of oncology rehabilitation (Part 1), the present state of the profession of Onc R (Part 2) and now we’ll complete our journey focusing on the future of Onc R, which is absolutely magnific! So buckle up my friends!

My colleagues Chris Wilson and Lori Boright have traveled with you through the incredible levels of evolution that our profession has completed to bring Onc R to not only Michigan but globally. We are so thrilled every day to read the rigorous research published regarding rehab for persons diagnosed and living with and beyond cancer (PDLWBC), to celebrate the collaborations among clinicians all over the world as well as the new Onc R programs being created constantly, and acknowledge and praise all rehab professionals including occupational therapists, certified occupational therapist assistants, speech language pathologists, social workers, involved at all levels of care for PDLWBC. It is so very exciting! The physical therapy  profession is truly leading the way as a catalyst for increasing quality of life for all PDLWBC. We feel especially blissful as we published our textbook entitled Oncology Rehabilitation: A Comprehensive Guidebook for Clinicians (https://www.elsevier.com/books/oncology-rehabilitation/doherty/978-0-323-81087-6). This book was co-edited by Chris, Lori and me but we are blessed to have 56 additional authors from 17 states and 4 countries bring their Onc R expertise to the written word. There are so many incredible therapists leading the world-wide charge to improve the lives of PDLWBC that it makes my heart sing!!

You might think that this is it. How could we do more?  Well, the physical therapy profession is just getting started. Let’s explore the possibilities! The residency programs are growing in number so now it is time to develop “Fellowships”. These may include advanced specializations such as research, pediatric oncology, oncologic pelvic health, and acute care oncology to name a few - and we have colleagues in the national arena that are working on this opportunity right now.

The concept of rehab navigation is a new and exciting area; imagine having a rehab professional who manages all aspects of movement and function with a PDLWBC throughout their entire cancer journey and into survivorship. There are currently a small and mighty group of individuals pioneering this role, but it is growing rapidly and once again the physical therapy profession is leading the way. This new area of specialty will allow patients to receive rehab earlier in their continuum of care and help prevent the severity of adverse effects (AEs) from cancer treatment.

The oncology population is desperately in need of frequent and reimbursable telerehabilitation. Their mental, physical, psychosocial, and psychoemotional stability is challenged daily during and after treatment for cancer. Having easy access to rehab via telerehab can provide continuity of care during times when patients can’t travel to a clinic. Oh, I know that some of you are shaking your heads saying that insurance just won’t pay for it and do not see the value. Well then, we are going to change that! As doctors of physical therapy and licensed physical therapist assistants, we can no longer stand by and just accept the health injustices put upon our profession but more importantly put upon our patients. Once again, we are leading the charge in bringing health justice to cancer care.

And while we’re on the subject of health justice, the utilization of artificial intelligence in rehabilitation is not only fascinating but essential to bring Onc R to geographically remote individuals. This allows information and communication technologies to assist (synchronously and asynchronously) in the decentralization of Onc R for those facing traditional logistical challenges to rehab, including time, distance to travel, difficult terrains, costs, and limited access to clinical facilities. And since the future absolutely has opened the door to treating patients in and outside of our state, there will be more work needed to assist the changes in state laws that currently prohibit interstate rehabilitation services; this can be achieved by the growing interstate licensure compact (https://www.apta.org/your-practice/licensure/licensure-compact). We will once again lead the way!

The previous blogs highlighted how Onc R should begin at the time of diagnosis. I couldn’t agree more. There is a small scattering of hospitals that have standard orders on the inpatient units for all persons diagnosed with cancer to receive a physical therapist (PT) consult. The goal is that Onc R becomes standard of care for every single person diagnosed with cancer; that a PT is an essential component of every cancer care team/tumor board/survivorship clinic; and that patients have easy access to a PT consult and whatever follow-up care is needed in every setting including inpatient, outpatient, inpatient rehabilitation, skilled nursing facility, palliative care, and hospice care. This aims to provide Onc R to not only every single person diagnosed with cancer but also guarantees special emphasis on those that are currently marginalized and undertreated.

I am very passionate about lifestyle medicine and humanistic care, incorporating cultural norms and beliefs as well as integrative therapies into our practices and truly treating each ‘person’ not treating diseases or AEs. I am proud that our profession is making substantive changes in entry-level education as well as clinical practice to try and incorporate these treatment philosophies into our profession, however, we need to be more comprehensive with our care through addressing all a patients’ needs. Once again, we will lead the way in making this the rule instead of the exception! The great news is there is hard work going on in many states right now to change the laws so that PTs are autonomous healthcare practitioners, where patients no longer will need the often-unnecessary administrative barrier of a prescription to access physical therapy services. This is absolutely the future of the physical therapy profession. I have no doubt that in the near future, PTs across the nation will be able to treat patients diagnosed with cancer without struggling to convince the medical community that rehab is essential. We will also help insurance companies to recognize the value of Onc R as early rehab intervention saves money, decreases the prevalence of AEs from cancer treatment, and provides the opportunity for every person to enjoy quality of life after cancer.

But wait, there’s more! The care that I have been referring to throughout this blog is secondary, tertiary, and quaternary prevention. Secondary prevention refers to prehabilitation, education, and consultation at the moment of diagnosis to prepare a person for the treatment of cancer. Tertiary care is where PTs “live” most of the time…treating the AEs caused from the cancer and the treatments for cancer. Through education and traditional physical therapy interventions we can prevent, mitigate, and manage AEs. Quaternary care is preventing the overmedicalization of care, which is our role as rehab navigators, members of cancer care teams, tumor board committees, survivorship clinics, and more. But let’s not forget about primordial and primary prevention. PTs are very well positioned and have the expertise to help with community and individual prevention of cancer. Primordial prevention requires changes in local and state laws to build, create, and implement programs and spaces that provide safe, easily accessible opportunities for physical activity (walking/biking paths), good nutrition (farmers markets located in food deserts), decreasing stress (group community programs of education, support groups, meditation) and so much more. Primary prevention is the individual lifestyle behaviors that can actually prevent cancer from occurring. The research is abundant and provides lots of guidance that healthy eating, good sleep, stress reduction, daily physical activity, spiritual practices, and related behaviors can positively impact epigenetic changes and decrease systemic inflammation (a driver of cancer) which will reduce the risk of cancer development. Once again, we will lead the way in the primordial and primary prevention domains!

Isn’t this absolutely epic?! The future of Onc R is crazy exciting, filled with so many possibilities, so many evolutionary leaps and bounds and PTs are up to the challenge! We have such great leaders nationally and globally that I have no doubt that in not too many years this blog will highlight exactly these successes and the continued evolution of our great profession!

Blessings to all of you!

 

Deb Doherty, PT, PhD is an associate adjunct professor at Oakland University in Rochester, MI. Deb is retired from clinical practice and continues to work as a cancer coach and participates in research focusing on oncology rehabilitation. She is the co-editor of the book entitled Oncology Rehabilitation: A Comprehensive Guidebook for Clinicians published by Elsevier. Deb also serves as the chair of the Research Committee for the APTA MI Onc Rehab SIG as well as a frequent lecturer on Onc Rehab to clinicians, students and survivors.

 

 

Nearly eight years ago, Oakland University physical therapy researchers were contacted by the Auburn Hills Community Senior Center director, Karen Adcock, who identified a gap in her ability to fully meet the needs of the older adults in her community. She and her staff were observing older adults with physical decline and believed a healthcare assessment was warranted. However, as the older adult’s decline was not always associated with a specific medical diagnosis, the individual did not meet the “traditional” paradigm for rehabilitative focused physical therapy.

What the senior center staff had likely been observing were individuals who were pre-frail or possibly even frail. In 2011, Fried et al. were among the first to suggest frailty to be a clinical syndrome that includes the presence of at least three of the following: unintentional weight loss, self-reported exhaustion, grip strength weakness, slow walking speed, and low physical activity.1 Frailty is an independent predictor of fall events, worsening mobility or disability, hospitalization, and death.1

Dr. Chris Wilson and I were at the table for the early discussions with the Auburn Hills Community Senior Center related to this recognized need. He and I identified an intersection between our scholarly agendas and passions that ultimately proved valuable to address this concern.  Specifically, Dr. Wilson’s research efforts include management of late-stage chronic disease and frailty in older adults and my efforts are aimed at implementing upstream and prevention focused approaches in community dwelling and home-bound individuals. We both fully appreciated the gap in care for the older adults Karen Adcock identified as they were all too familiar within our own clinical practices. I suspect many other physical therapists have often had this thought when providing care to an older adult, “If I had only seen this patient 6-months ago maybe this --insert a preventable condition or event-- could have been prevented.” It was during these early discussions with the Auburn Hills Senior Center that the home-based older persons upstreaming prevention physical therapy (HOP-UP-PT) foundational independence program was conceived.

While there are evidence-based screenings available to physical therapists that can identify functional decline, environmental risk, and prevention focused interventions, often times a rehabilitative approach to care (versus a prevention-focused approach) is still the predominant industry norm when seeking and providing physical therapy services. Notably, early conceptual framework development for what is now known as the HOP-UP- PT program, came about soon after the State of Michigan approval of direct consumer access to physical therapy services. This provision opened additional opportunities to shift the paradigm in the delivery of care for persons seeking a physical therapist for the purpose of preventing injury or promoting fitness without a physician referral.

The HOP-UP-PT program uses direct referral to physical therapists from the community; thereby, bridging public/community health by way of physical therapists as the entry point into the medical/healthcare system. To date the program has received more than $500,000 in grant funding, has 13 peer reviewed publications, and numerous state and national presentations that support the program’s positive impact on reducing the negative sequelae of aging. This includes the published outcomes of a randomized clinical trial examining the impact of the HOP-UP-PT program on older Michiganders.2 Specifically, the clinical trial provides evidence of an 8-fold decrease in those at highest risk of a fall event as well as statistically significant reductions in fall risk metrics among all HOP-UP-PT program participants.

Furthermore, an open access master class article titled, “State of the Art Physiotherapist-Led Approaches to Safe Aging in Place” provides evidence for the utility for specific tools and identifies the HOP-UP-PT program as a case example of best practice for safe aging in place.3 The article further suggests programs “integrating both community and healthcare approaches have strong evidence for their utility; however, implementation for these preventative approaches are lagging behind” given the exponential population growth of those over 65 years.”3

Another publication which analyzed adjunctive data available from the clinical trial suggests physical therapists providing care the direct consumer access approach should routinely “incorporate cardiovascular and cognitive screenings with strong psychometric properties to assure safety for older adults prior to engagement in PT-led prevention programs.”4 Despite this evidence and the availability of direct access to physical therapy services for preventions focused interventions, reimbursement for this approach remains vague and illusive. This presents an inherent risk many physical therapists are not willing to take on.

Research related to reimbursement of the HOP-UP-PT program is ongoing using support from a Michigan Health Endowment Fund-Healthy Aging award. This has championed opportunity for Oakland University Physical Therapy researchers to explore reimbursement of prevention-focused services. To that end Drs. Chris Wilson, Lori Boright, and I are collaborating with Henry Ford Home Health Care to provide the program to older adults and then examine the reimburse and administrative outcomes. Using the traditional Medicare Part B reimbursement pathway most commonly employed in the outpatient physical therapy practice setting, the home healthcare agency applies its expertise in community and home healthcare delivery to provide the HOP-UP-PT Foundational Independence Program.

An early pilot study of six older adult HOP-UP-PT participants had promising outcomes which we aim to further support with a more robust sample that is currently in the data collection phase. Another important aspect of the collaborative efforts with Henry Ford Home Health Care has been transitioning the paper evaluation and visit documentation used in the earlier research into an electronic medical record format. This has associated costs of financial and administrative resources that are also being analyzed as component of moving the program into clinical practice. This approach has been a practice pattern shift for home healthcare providers who most frequently provide care to homebound individuals. Naccarato et al. describes administrative barriers to this innovative delivery model including challenging reimbursement consideration and uncompensated travel time.5 However, it is necessary for the physical therapy discipline to continue to advocate for care models and reimbursement practices that best meet the needs of the aging population.

Does prevention focused physical therapy care for older adults sound interesting to YOU?

Education on the delivery of the HOP-UP-PT foundation independence program has been created, tested, and is now approved for 4 hours of State of Michigan continuing education as an asynchronous learning opportunity here. Additionally, a free community ambassador training education is available on the HOP-UP-PT website.

Some older adults may need additional prevention focused education. To address this issue, educational modules created with the intention of delivery by physical therapists and physical therapy assistants to older adults have been developed and are available upon request. Community facing education videos are now available for safe fall recovery, urinary incontinence and fall prevention, frailty, Timed Up and Go Test, Otago Level B, and motivational interviewing. In addition to corresponding educational content for these videos, content on physical therapist delivered emergency readiness in the home and technology literacy assessment and interventions are available.

Physical Therapist led prevention-focused approaches offer an opportunity to expand the value of healthcare delivery while concurrently improving the quality of life among older adults. The physical therapy profession is “well positioned to embrace a prevention focused paradigm shift to become gateway healthcare providers with targeted approaches that empower older adults to stay safe and active in their homes and community using programs such as HOP-UP-PT.”6

 

Sara Arena PT, MS, DScPT

Professor and Director of Oakland University Physical Therapy Program

Co-principal of HOP-UP-PT

arena@oakland.edu

 

 

 

 

 

 

References:

1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156. doi:10.1093/gerona/56.3.m146

2. Arena SK, Wilson CM, Boright L. et al. Impact of the HOP-UP-PT program on older adults at risk to fall: a randomized controlled trial. BMC Geriatr 21, 520 (2021). https://doi.org/10.1186/s12877-021-02450-0

3. Wilson CM, Arena SK, Boright LE. State of the Art Physiotherapist-Led Approaches to Safe Aging in Place. Arch Physiother 12, 17 (2022). https://doi.org/10.1186/s40945-022-00142-5

4. Arena SK, Wilson CM, Boright L, Webster O, Pawlitz C, Kovary C, Esper E. Medical Clearance of Older Adults Participating in Preventative Direct Access Physical Therapy. Cureus. 2023 Mar 5;15(3).

5. Naccarato A, Wilson CM, Arena SK. Perceptions of Rehabilitation Managers on Implementation of the Home-Based Older Person Upstreaming Prevention (HOP-UP) Program: A Retrospective Qualitative Analysis. Cureus 13(4): e14760. doi:10.7759/cureus.14760

6. Wilson C, Arena S, Boright L. Home-based Prevention Care to Facilitate Safe Aging in Place: The HOP-UP-PT Case Example. GeriNotes. 2022; 29(2):24-30.

 

 

The hallmark of physical therapy residency programs is intense mentorship to expand the resident’s clinical experiences and decision-making processes. A residency would also assist in further developing the resident as a clinician to better understand and treat patients with varying levels of complexity. As each physical therapy residency program focuses on a unique setting and individualized approach, various learning opportunities are available depending on the program.

My decision to pursue a residency program following physical therapy school was preceded by guidance from faculty members, previous clinical instructors, and self-reflection. Several months before the application deadlines, I began reflecting on what areas I wanted to grow in throughout the residency program. This process assisted in developing my program criteria when seeking out residency programs. Three of the main deciding factors included the culture of the mentorship, the opportunities for the resident to grow as a clinician during the program, and the setting/population of the rotation(s) within the residency. I was interested in programs that incorporated patient care, research, teaching, and also had a high emphasis on intentional mentorship.

Initially, I was interested in two different settings but ultimately decided to pursue a program in the acute care setting. Specifically, I was interested in obtaining training in areas that incorporated multiple patient populations with varying diagnoses. Additionally, having personal experiences within the field of oncology, I sought out a specific program which included an oncology rotation during the residency. This program also incorporates triple the amount of required mentorship for an ABPTRFE-accredited residency program, along with a high emphasis on functional-based research. Furthermore, the teaching component included in this residency program would assist in expanding my knowledge and teaching capabilities in an accelerated and individualized manner.

I decided to apply to six different residency programs (3 in outpatient orthopedics and 3 in acute care) and utilized the time between application deadlines and interviews to determine which setting I wanted to pursue. The application processes were highly time-consuming, as each application included various essay portions. Additionally, I was able to highlight volunteer, leadership, and award opportunities throughout my application in various components. Lastly, I asked both faculty mentors and clinical instructors to write my letters of recommendation for the residency applications.

At the time, it was highly overwhelming to have applied to six different programs. However, looking back, I am thankful for the many interview experiences this provided me. I remember reading the email that I received an interview for my top choice, and I constantly re-read the email throughout the day to ensure I read it correctly. This was my third interview for a residency program, yet by far the most challenging that I had completed. It began with a virtual tour of the facilities and a question-and-answer with the current resident. I appreciated this component as I was able to conceptualize the culture and learning environment instilled in this residency program. Having past interview experience, I felt as though I had a better grasp of what I was looking for in a residency through not only the curriculum but, more importantly for me, the intentional community of the residency mentors. Through discussion with the current resident, it appeared to me that the faculty mentors not only truly cared about her pathway to becoming a more well-rounded clinician, but also her overall well-being and ability to balance the rigorous nature of the residency program. The next portion of the interview included a case study, where I was given time to review a case and take notes, followed by questions from the faculty mentors regarding the case. Personally, this was a very challenging component for me as I had difficulty answering some of the case study questions. However, it was through this difficult time that I was able to further witness the encouragement and exceptional mentorship skills that were present in the faculty mentors. Because I felt as though I did not perform well in the case study, I remember telling myself to take some deep breaths and show my true personality and willingness to learn throughout the remainder of the interview. The last portion included a more typical question-and-answer session. I was able to highlight various volunteer opportunities that I have been involved in, my reasoning process in deciding to pursue residency training, and the extensive research project I have been involved in facilitating throughout physical therapy school. The program director informed me at the conclusion of the interview that I should hear from them within several days regarding my acceptance or denial from the program.

After completing the interview, I remember running into a faculty mentor, who had written one of my letters of recommendation for this program and who had been highly influential and encouraging in my desire to pursue a residency program in the acute care setting. We discussed how I felt the interview went and she reminded me that whatever happens has a reason and I have put significant physical, mental, and emotional effort into this process and should continue to believe in myself. Several days had passed since the interview but I had not heard any news. Nearly one and a half weeks later, I received an email from the program director that the HR representative had been out of the office, but they would like to extend the offer to me. I happened to be at the APTA-MI Student Conclave that Friday afternoon, when I received the email. I could not have asked to be surrounded by more supportive faculty, friends, and classmates at this time. After the initial sense of shock, I felt a peace come over me and the stress of the past several months of applications, interviews, and decisions on acceptance melt away. I am thankful for the exceptional guidance from numerous faculty members and clinical instructors that I have received throughout this process.

I am looking forward to pursuing an acute care physical therapy residency and learning in an intense and individualized manner. One of my contributions to the physical therapy profession in the next several years will be to further the research on specific populations or diagnoses, which do not have a significant amount of data yet in that area. Becoming more involved in the field of acute care physical therapy will also allow me to utilize the skills learned throughout the residency program to benefit the patients we serve. As the residency will assist in expanding my knowledge and confidence in physical therapy, I will continue to advocate for the field of physical therapy to expand the knowledge to the general public.

Kelsey Florian, SPT is a third-year physical therapy student at Grand Valley State University and will be graduating in July of this year. Following graduation, she will be pursuing an acute care physical therapy residency on the east coast to further expand her clinical decision-making processes along with her teaching, research, and clinical experiences.

 

 

The first installment of this three-part series for APTA MI Lines blog focused on the past of oncology rehabilitation, our roots and early development into a specialty area of practice. This second installment aims to present the current status of oncology rehabilitation, in the domains of clinical practice and education (both entry level and post professional). As my colleague, Chris Wilson, so eloquently introduced in part one, Michigan really is on the forefront of this specialty area of practice. In addition to our collaboration with Deb Doherty on our textbook publication (Oncology Rehabilitation: A Comprehensive Guidebook for Clinicians. https://www.elsevier.com/books/oncology-rehabilitation/doherty/978-0-323-81087-6), we have also all been very involved in our state and national professional associations, Deb and I founding APTA MI Oncology Rehabilitation Special Interest Group (SIG) and Chris serving multiple roles within APTA Oncology at the national level. Presently, Deb serves as APTA MI Oncology Rehabilitation SIG Research Chair and I serve as the Chair of the SIG. Chris, currently serves as the President of the academy. It is essential that we continue to serve in these roles and inspire others to do so as well to continue the advocacy efforts towards improved access to and quality of care provided as well as improved workforce capability to manage this growing population of patients.

Currently in the clinical practice domain, many cancer survivors do not receive a referral to an oncology rehabilitation specialist. It is ideal to start oncology rehabilitation at the time of diagnosis, to obtain baseline measurements, impart critical information about the treatment trajectory (the what to expects etc.), and establish a meaningful relationship so the patient will know how to access oncology rehabilitation services when they are needed, because as we all can appreciate, it really is not an if situation, but a when situation. Establishing oncology rehabilitation as standard of care takes effort, inclusive of imparting education on the value of oncology rehabilitation services to our referral sources. APTA MI Oncology Rehabilitation SIG leaders are currently providing this valuable education to several medical schools within the state towards this end. I do not contend that our colleagues intentionally withhold the option of oncology rehabilitation for their patients, many are unaware of the benefits and even more still are hyper-focused on their discipline and the business of life saving. An esteemed colleague of mine, Meghan Burkhart, once said, “medical, surgical and radiation oncology add days to life, oncology rehabilitation adds life to days,” and I could not agree more.

Currently in the education of the clinical workforce domain, APTA MI Oncology Rehabilitation SIG is leading the nation once again in that our leadership has prepared and provides an entry level oncology rehabilitation course to every DPT program in the state of Michigan! Nationally, APTA Oncology is committed to facilitating provision of entry level content, having just established entry level criteria, efforts are now focused on developing resources for programs to deliver this critical information. Post professional opportunities to acquire advanced practice skills have become more widely available and include residency, certificate programs, and virtual and in-person continuing education courses. All one need do is perform a simple Google search to begin the process of acquiring skills and knowledge to improve the lives of cancer survivors through rehabilitation. Michigan has the first graduate certificate in oncology rehabilitation at Oakland University (https://oakland.edu/online/online-programs/GCOR) ), a fully online post professional opportunity to network with a global clinical workforce while growing your skills and abilities to provide holistic assessments and interventions in the oncology domain. Additionally, efforts to educate our colleagues in medical oncology are ongoing and essential to ensuring that every person living with and beyond a cancer diagnosis has access to the quality of life enhancing benefits of oncology rehabilitation.

Toward these crucial ends, leadership by example continues to be the emphasis here in the mitten state. We are proud to have the first state level SIG dedicated to clinical best practice development and patient advocacy, have provided a white paper on how we accomplished this feat, and continue to mentor other states to follow in these impressive footsteps. I encourage all who have an interest in practicing in this area, even if you do not want to work full or part time with this population, to join the SIG to network with nationally and globally recognized leaders in oncology rehabilitation. Your future patients will thank you!!! Please use the QR code below to advance your network and connect with the SIG!

Please stay tuned for our third installment in this series for the Lines blog! Deb Doherty will be discussing the future of oncology rehab!

 

Lori Boright PT, DPT, DScPT, CLT is an Assistant Professor at Oakland University and is a practicing physical therapist at Ascension South East Michigan, where she is responsible for leading clinical research initiatives and the statewide development of Oncology Rehabilitation across care settings.

 

How long after a stroke is recovery possible? This is a common question individuals ask in physical therapy after experiencing a stroke. Usually, they have heard that most progress happens in the first 6 months. To me, this is a complicated question to answer. I have found, clinically, individuals can make progress after 6 months, but this is not always communicated appropriately to people after they have had a stroke. Research does show that spontaneous recovery occurs in the first 3 months post stroke.¹ Therefore, individuals in the acute and subacute phases are going to show more progress in rehab at this time. So what does this mean for people post stroke that fall beyond this timeline, also known as a chronic stroke? Research has shown at this stage, recovery slows or plateaus in comparison to the acute phase.² However, this does not mean that you cannot make significant progress in their physical therapy during this time.

Prevalence and Morbidity

            There are approximately 795,000 people that experience a stroke in the United States each year.³ Up to 50% of stroke survivors experience chronic disabilities.⁴ Physical disabilities are often related to balance and gait issues. With these type of impairments, we see decreased quality of life scores and difficulty participating in daily life.⁵ Given this information, the chronic stroke population cannot be ignored in the physical therapy community. So how can we help these individuals with research telling us that recovery slows at this stage?

Walking

            The American Physical Therapy Association (APTA) released a clinical practice guideline (CPG) for chronic stroke that provides recommendations on the best strategy of care for this population in regards to locomotor function.⁶ Based on their research, walking at moderate to high intensity (60-80% of heart rate reserve) seems to be the best way to see results. Walking duration varied from 20-60 minutes and was performed anywhere from 2-5x a week over 1 to 6 months in the studies reviewed. Sessions could be performed overground or on treadmill. Improvements were seen in 6 minute walk test, 10 minute walk test, and walking speed. Most of the studies focused on consistent walking staying in the 60-80% of heart rate reserve range. Two studies had a slightly different protocol focusing on interval treadmill training. When compared to the same treatment but performed at a lower intensity, the higher intensity groups demonstrated more progress in gait.
         So how do we apply this information to our patients? I think the first step is to evaluate if we are pushing this patient population enough to evoke a change. Perhaps, this is the reason a plateau is occurring in physical therapy with these individuals. It is vital that we are measuring target heart rates to monitor the intensity of the exercise routine. As we see above, if the walking program is too easy, it is not going to make a significant difference.

Balance

            Balance issues are another long term consequence of chronic stroke. Can these be improved in the chronic stage as well? Research says yes. A systematic review and meta-analysis was performed on the effects of exercise therapy on balance in the chronic stroke population.⁷ Training strategies were categorized as balance and/or functional weight-shifting training, gait training, multi sensory training, high-intensity aerobic training, and other training programs. The chronicity after stroke ranged between 7 months to 7.7 years. Balance, as tested by Berg Balance Scale, Functional Reach Test, and Sensory Organization Test, improved after programs focusing on balance/weight shifting and gait training.                                                     Based on this information we can say that working on balance can improve in individuals with chronic stroke. However, because this study included such a variety of different balance interventions, it is difficulty to say what interventions would be the most efficient and effective to improve balance. Perhaps, future studies will provide more insight on this topic. In the mean time, it may be best to focus on what we know about neuroplasticity and task specific training. Task specific training has shown to promote motor learning and cortical reorganization.⁸ For this reason, focusing on static and dynamic balance tasks that individuals experience in daily life would be the best to focus on in their physical therapy interventions.

Neuromuscular Electrical Stimulation

            Another treatment strategy that has helped individuals with chronic stroke is neuromuscular electrical stimulation or NMES. A systematic review looked at the effect of NMES on lower limb function.⁹ To evaluate the effect on lower limb function, gait speed, balance, spasticity and range of motion, and walking endurance were used. The review found an improvement in gait speed, balance, tone, and range of motion. Measures to evaluate improvements were gait analysis, 10 minute walk test, 6 minute walk test, Berg Balance Scale, Timed up and go, and Modified Ashworth. An important note of this systematic review is that NMES was only effective when combined with other treatment strategies than with NMES alone.                    Using this information, we can use NMES as an adjunct to physical therapy interventions. It can be used to assist with motions that may be difficult for individuals in functional tasks. For example, applying electrodes to dorsiflexors can assist with foot drop during heel strike in gait. In addition, using electrodes on finger extensors to open hand to prepare for gripping activities.

Conclusion

            I hope that providing this information changes clinicians minds about chronic stroke and the possibility of continued recovery. I think that this population is often ignored because we are told that progression is not going to happen after 6 months. However, we have seen in research that it can. We have to change our treatment strategies for these individuals in order to challenge them and promote improvements. Hopefully, future studies will continue to give guidance on why these patients may reach a plateau in therapy and how we can avoid it.

Audriana Spadaro is an outpatient physical therapist who works mostly with individuals with neurological disorders. She graduated from University of Michigan-Flint with her Doctor of Physical Therapy degree in 2016. She has been with Henry Ford Health for 6 years. She is certified in LSVT BIG and PWR!Moves. In her free time, she enjoys hiking, horseback riding, walking her dog and chasing around her 1 year old son.

 

 

 

 

 

References

1. Cramer SC. Repairing the human brain after stroke: I. Mechanisms of spontaneous recovery. Ann Neurol. 2008 Mar;63(3):272-87. doi: 10.1002/ana.21393. PMID: 18383072.
2. Teasell RW, Murie Fernandez M, McIntyre A, Mehta S. Rethinking the continuum of stroke rehabilitation. Arch Phys Med Rehabil. 2014 Apr;95(4):595-6. doi: 10.1016/j.apmr.2013.11.014. Epub 2014 Feb 14. PMID: 24529594.
3. Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, et al. Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association. Circulation. 2022;145(8):e153–e639.
4. Donkor ES. Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life. Stroke Res Treat. 2018 Nov 27;2018:3238165. doi: 10.1155/2018/3238165. PMID: 30598741; PMCID: PMC6288566.
5. Schmid AA, Van Puymbroeck M, Altenburger PA, Miller KK, Combs SA, Page SJ. Balance is associated with quality of life in chronic stroke. Top Stroke Rehabil. 2013 Jul-Aug;20(4):340-6. doi: 10.1310/tsr2004-340. PMID: 23893833.
6. Hornby TG, Reisman DS, Ward IG, Scheets PL, Miller A, Haddad D, Fox EJ, Fritz NE, Hawkins K, Henderson CE, Hendron KL, Holleran CL, Lynskey JE, Walter A; and the Locomotor CPG Appraisal Team. Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury. J Neurol Phys Ther. 2020 Jan;44(1):49-100. doi: 10.1097/NPT.0000000000000303. PMID: 31834165.
7. van Duijnhoven HJ, Heeren A, Peters MA, Veerbeek JM, Kwakkel G, Geurts AC, Weerdesteyn V. Effects of Exercise Therapy on Balance Capacity in Chronic Stroke: Systematic Review and Meta-Analysis. Stroke. 2016 Oct;47(10):2603-10. doi: 10.1161/STROKEAHA.116.013839. Epub 2016 Sep 15. PMID: 27633021.
8. Takeuchi N, Izumi S. Rehabilitation with poststroke motor recovery: a review with a focus on neural plasticity. Stroke Res Treat. 2013;2013:128641. doi: 10.1155/2013/128641. Epub 2013 Apr 30. PMID: 23738231; PMCID: PMC365950
9. Hong Z, Sui M, Zhuang Z, Liu H, Zheng X, Cai C, Jin D. Effectiveness of Neuromuscular Electrical Stimulation on Lower Limbs of Patients With Hemiplegia After Chronic Stroke: A Systematic Review. Arch Phys Med Rehabil. 2018 May;99(5):1011-1022.e1. doi: 10.1016/j.apmr.2017.12.01 Epub 2018 Jan 31. PMID: 29357280.

 

 

Where have we been, where are we now, where are we going?  Every PT and PTA uses these questions to reflect on a patient’s progress, their own professional development, and the status of the profession that they love. This Lines blog post is the first in a series of three blogs which will contain some personal and professional reflections on how the physical therapy profession has grown into and embraced its role in treating people with cancer – also known as oncology rehabilitation. Yours truly, Lori Boright, and Deb Doherty have each composed a blog on the growth of the physical therapy profession in caring for people with cancer.  I will be focusing on the past, Lori will speak to the present, and Deb will hop in her DeLorean and go 88 miles an hour to look into the future (for those that didn’t get that reference, its Back to the Future!...a classic 80s movie).  Deb, Lori, and I are very passionate about this topic as we are the three co-editors of the just released book entitled Oncology Rehabilitation: A Comprehensive Guidebook for Clinicians. https://www.elsevier.com/books/oncology-rehabilitation/doherty/978-0-323-81087-6.  In addition to Deb, Lori, and I being instructors at Oakland University, this book has LOTS of Michigan ties as over HALF (yes, you read that right) of the chapter authors have practiced in Michigan.  I like to think of Michigan as the Oncology Rehabilitation Capital of the World (© Chris Wilson 2023) as we really have a strong professional network in our lovely state! If you or anyone you know needs oncology rehabilitation, Michigan truly is a great place to be!

Sadly, most PTs and PTAs know about the physical therapy treatment for persons diagnosed with cancer from what they WEREN’T ALLOWED to do with their patients, and this was hardwired into them in their entry-level education.  Patient has cancer – don’t do modalities!  Patient has cancer – don’t do manual therapy!  Patient has cancer – they need rest, don’t exercise them!  A lot of what we were taught was so well intentioned but so wrong…  Now, indeed there are some cases where specific modalities or aggressive joint mobilizations might not be best for certain patients with certain circumstances but for the most part, they are people who need physical therapy and can benefit from a lot of our treatments and are not getting them!  That was why we wrote our book, to educate people that all physical therapy treatments have a role for persons with cancer, it’s just the when and where that are important. 

In the past, we didn’t have the answers to a lot of our questions about patient safety when it came to oncology rehabilitation.  When in doubt, patient safety comes first; if we aren’t sure if a treatment will help a patient and there is a small or unknown chance of harm, the principle of ‘first do no harm’ always comes first – as it should!  In a lot of organizations, oncology rehabilitation started from a lymphedema program because that was something that could not be ignored and was relatively safe to treat with very good outcomes.  Of course, what did these lymphedema-trained therapists find once they were working with these patients? Lots of other problems caused by the cancer or its treatments – fatigue, weakness, stiffness, balance disturbances, pain, loss of range of motion, neuropathy, to name a few. Although likely hesitant to open up these other ‘cans of worms’, these therapists recognized and attempted to treat these other issues to improve their patient’s quality of life.  Of course, this begs the question – if patients with lymphedema have a lot of these ‘other’ issues, how many patients without lymphedema also have these issues and why aren’t we seeing them?  We probably should be.  This is where advocacy, research, and education needed to come to the forefront! Over the past 25 years, there have been an ever-growing body of research showing that not only are physical therapy treatments like exercise and manual therapy not harmful, they are essential. We now have evidence-based Clinical Practice Guidelines on a variety of topics including lymphedema and cancer related fatigue. Many national organizations are now endorsing that every person with cancer needs to exercise.  This exercise can reduce adverse effects of cancer and even…wait for it…improve survival rates and recurrence rates of cancer.  Yes, something we do every day with patients can literally save lives.  If the evidence is continuing to grow about the PTs/PTAs role in oncology rehabilitation, why doesn’t it happen consistently?

It’s not an understatement to say that cancer and its treatments are complex and evolving topics. There are lots of unique medical terms that we usually don’t encounter in physical therapy (neoadjuvant, consolidation, nadir…oh my!).  Behind these terms are very complex treatments and dozens of other professionals who have decades of training in their highly specialized areas of practice.  This can be intimidating for a PT or PTA who might know the right thing to do to address their patient’s impairment but doesn’t want to do the wrong thing.  This is where each PT and PTA should consider filling their knowledge gaps as it relates to cancer.  Don’t worry, this does not have to be an extensive, expensive process.  Just an introductory course or two is usually a great start.  Almost every PT online learning center has an intro to cancer rehab course.

Another issue is how much education is needed? For some reason, some therapists feel that they can’t treat a patient with cancer because they are not a specialist.  This is not true.  Now indeed, some patient cases are complex and do require the skills of a specialist but just like ortho or neuro, one does not have to be a specialist to see a straightforward patient with an orthopedic or neurologic condition – just a solid foundation in the principles of the area.  The difference is we get this solid foundation in our entry level training for ortho and neuro, but not for cancer…yet! Lori and Deb have done an amazing job traversing the state of Michigan to speak to every DPT student in all of the entry level programs.  I am also proud to have been the co-chair of a task force to establish a document as to what every new grad should come out of school knowing about cancer and cancer rehab that was just released in Feb 2023 and can be found on the Academy of Oncologic Physical Therapy’s website https://oncologypt.org/publications/#CPG. So there is hope that all PTs and PTAs will have some foundational knowledge of cancer in the future! 

The specialty of oncology rehabilitation is no longer in its infancy!  I would say that we are in our adolescence; yes, adolescence often comes with awkwardness and a sense of uncertainty BUT with adolescence also comes unbound potential and inspiration to change the world!  This is why I’m excited about our profession’s efforts to address this major health issue. Cancer is the second leading cause of death in the US and our society and community are looking to us to address their movement issues from cancer. Our treatments are able to prevent, mitigate, or manage the various adverse effects of cancer and its treatment, improve quality of life, and even reduce the risk of recurrence. We have the tools and the knowledge to help people facing the fight of their lives, we can be part of the team that helps them during their journey – now we just have to step up to the plate.  Join us for the next Lines blog post where Lori Boright will discuss the current state of oncology rehabilitation including the topics of education, residencies, and specialization.

Stay tuned!

Chris

Chris Wilson PT, DPT, DScPT is an associate professor and director of clinical education at Oakland University in Rochester, MI. He practices clinically at Corewell Health Acute Care Oncology and is a faculty member in the Corewell Health Oncology Residency for physical therapists. He is the co-editor of the book entitled Oncology Rehabilitation: A Comprehensive Guidebook for Clinicians published by Elsevier. He is a delegate for Michigan for the APTA House of Delegates and is the President-Elect of the Academy of Oncologic Physical Therapy.

 

 

An effective, dedicated, and passionate pediatric physical therapist is a rare find. After all, there are only just over 4350 of us representing this profession in the US (Zippia, 2022). We should be proud of our commitment to the habilitation and rehabilitation of young individuals and our distinct knowledge, skills, and abilities that set us apart from other specialties. Whether we work in home care, the hospital, outpatient clinic or school setting, we all strive to help kids function to their fullest potential, advocate for families, and promote health and wellness all while we pledge to continue to learn and grow even faster than our own patients!

 What does it take to learn the ropes of this specialty area?  How do we continue to thrive and develop professionally without suffering from burnout? Most of us become bored before our patients get tired of the same games, toys, and tricks. Pediatric physical therapists must not only continue to follow the evidence and provide intervention supported by research, but also need to be creative, fun, and energetic.  We are a unique breed of individuals who demonstrate patience, resilience, and adaptability. Working with children presents a number of unique rewards and challenges. Kids are not simply miniature adults: they are dynamic and vulnerable, and their growth and changing needs must be facilitated and supported. Having an in-depth understanding of typical and atypical development, and navigating obstacles related to behavior, communication, and parenting styles can make all the difference in the world when treating children and maintaining a focus on participation and family-centered care. As devoted healthcare providers, pediatric physical therapists are continuously seeking cost-effective and constructive ways to build upon our evaluation, assessment, and intervention tools. We avoid stagnation and are always seeking new knowledge to continue evolving our practice.

We decided to ask our APTA Pediatrics SIG friends and colleagues about their favorite resources. What has helped to enhance their knowledge and skills as clinicians? How do they stay current as pediatric physical therapists? As our little people would say, “Sharing is caring!”  We hope these recommendations add to your therapy toolbox, and make you even more excited to further develop your skill set as a pediatric PT!

What are YOUR favorite resources for pediatric physical therapy practice?

1.  Blogs

Pediatric physical therapy blogs are a great way to stay current with industry news and learn practical tips from clinicians around the world. Therapists report feeling inspired, and gaining insight and wisdom while spending only a minimal amount of time on a quick read.  Here are some recommendations:

• https://blog.feedspot.com/pediatric_physical_therapy_blogs/ 
• https://www.milestonepedstherapy.com/blog 
• https://starfishtherapies.com/blog/
• https://www.bigleapsct.com/blog
• https://www.pinkoatmeal.com/blog/

2.  Podcasts

Podcasts provide an entertaining alternative to visual media. They are easy to access and on-demand, allowing therapists to listen on a smartphone, tablet, or computer. Podcasts are a great way to learn engaging content while driving or relaxing. A short list of recommended podcasts for pediatric physical therapists:

• Pediatric Physical Therapy - Pediatric Physical Therapy Podcast: from the Journal of Pediatric Physical Therapy:
• Pushing Pediatrics: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiGmfDQlev8AhWRjIkEHRe_BVIQFnoECAwQAQ&url=https%3A%2F%2Fpodcasts.apple.com%2Fus%2Fpodcast%2Fpushing-pediatrics%2Fid1584118933&usg=AOvVaw2pq1QH9EGp2CuNTe0GO-Su (This is an educational podcast for pediatric physical therapists: created to help those studying for the pediatric certified specialist exam (PCS), and anyone else interested in learning more about pediatric physical therapy.
• The Working Therapist: Providing Helpful Ideas for Pediatric Speech, Occupational and Physical Therapy. (Podcast episodes include topics such as “Co-Treats and Collaboration: Strategies for the Speech, Occupational, and Physical Therapist”)
• WiredON Development: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiRourgmOv8AhVIjYkEHYlmCDkQFnoECAkQAQ&url=https%3A%2F%2Fpodcasts.apple.com%2Fus%2Fpodcast%2Fwiredon-development-interviews%2Fid1231213053&usg=AOvVaw0wXbxDfv7tpgPxTkDkV05D (Interviews sharing insight from brilliant clinicians in the field of neuromotor development and childhood disability… inspiring and motivating to pediatric PTs and OTs who have a thirst for knowledge)

3.  Continuing Education Courses/Webinars

Not only do pediatric physical therapists need 24 PDR credits to maintain their licensure in Michigan, but continuing education courses are a great way to keep current in their practice and improve overall clinical performance and patient outcomes. Since Covid, many courses continue to be offered online, both synchronously and asynchronously, allowing more flexibility for busy professionals. Here are a few sources that offer highly recommended continuing education opportunities for pediatric physical therapists, both in-person and online:

• Apply EBP: https://www.applyebp.com
• Liesa M. Ritchie (Persaud), PT, DPT, PCS: Know to Change: https://www.knowtochange.com
• APTA Learning Center: https://learningcenter.apta.org

4.  APTA Resources

The APTA is more than just a professional organization of physical therapists. Although individual pediatric PTs bring unique skills and expertise to our profession, we are undoubtedly stronger together!  Our association offers a plethora of resources and works relentlessly to publish and distribute valuable information for practicing clinicians. Many of these resources are easily accessed, educational, and concise. The APTA Michigan Pediatrics SIG highly recommends the following:

• Journal Club Meetings: APTA Michigan Peds SIG, APTA Academy of Pediatric Physical Therapy School SIG
• APTA Academy of Pediatric Physical Therapy Fact sheets: Supporting Development, Best Practice, Tests and Measures, Promoting Physical activity and participation, Across the Practice Settings, Populations, Interventions, and Spanish Language Fact Sheets
• APPT Clinical Practice Guidelines (CPGs): Concussion/Mild Traumatic Brain Injury, Congenital Muscular Torticollis, Developmental Coordination Disorder

5. Social Media Groups

In this modern age, social media is a quick and seamless way to network and build virtual professional learning communities. Social media groups provide a platform to share research, case studies, and creative ideas for pediatric intervention. Therapists can easily collaborate with colleagues across the globe through discussions and sharing of resources. Facebook, Instagram, Pinterest, Twitter, and even TicTok can be a source of feedback, inspiration, and support. Listed below are a few Facebook groups recommended by local pediatric physical therapists:

• Evidence based pediatric OTs and PTs
• The Wired Collective
• Pediatric Physical & Occupational Therapists
• Pediatric Therapy Discussion Board

And a few sources to follow on Instagram:

• Tinytotspt
• Acadpedpt
• Ginnypaleg
• Dinosaurphysicaltherapy

In this digital age, access to new information is only one click away! Listed above are only a few of the many wonderful resources to explore and supplement your pediatric physical therapy practice. We hope we have inspired your curiosity for seeking contemporary ways to support our patients and families, promoting their healthy development, participation, and independence in the home, school, and community.

Stacy Zousmer, PT, C/NDT, DScPT is a physical therapist with 24 years of experience working in pediatric outpatient and school settings. She serves as adjunct faculty in the Department of Human Movement Science, School of Health Sciences at Oakland University in Rochester, Michigan. She is a member of the APTA Academy of Pediatric Physical Therapy and a co-founding member and the Vice-Chair of the APTA Michigan Pediatrics Special Interest Group.

 

 

 

High impact chronic pain, defined as persistent pain with “substantial restriction of participation in work, social, and self-care activities for six months or more” (1), of nonmalignant origin has been an enormous burden on the quality of life of an individual and society. Chronic pain not only impacts physical limitations, but may likely effects emotional, social, vocational, recreational and legal aspects of someone’s life. Therefore, unimodal or singular treatment options such as pharmacological intervention, injections, surgery, physical therapy or spinal cord stimulators are not as individually effective in improving suffering and restoring a normal lifestyle for people with chronic pain when compared to multimodal approaches (2,3). Consequently, integrated and multidisciplinary approaches have shown to be superior in the successful treatment of chronic pain patients (2,3). We, as physical therapists, are part of one of such multiple disciplinary team at Henry Ford Health in Detroit, Michigan.  

 

What is the Multidisciplinary Pain (MDP) Clinic and How does the current MDP work?  

The MDP clinic offers longitudinal, patient-centered care where patients are evaluated and treated by a team of providers which include a pain physician, pain psychologist, physical therapist and nurse practitioner. The MDP clinic at Henry Ford Health is unique in the way that patients are treated in an outpatient setting over the course of a lifetime, while other MDP clinics are often intensive, partial inpatient programs that are several weeks long without long term follow-up.  

Once selected and referred to the program, an ample amount of time is dedicated to listening to the patient’s story to allow them to feel heard and provide a non-judgmental, supportive patient-provider relationship toward the path of recovery and functional independence. Our treatment is focused on behavioral changes through shared decision-making process. At the first MDP visit, patients are asked to identify at least one  functional goal (using the SMART principle, achievable by the next MDP visit in 6-8 weeks. Based on the evaluation and patient needs, individuals are referred to other providers such as a nutritionist, massage therapist, physical therapist, neurologist and so forth. If needed, appropriate lab work or diagnostic testing is ordered. At the next visit, the patient’s self-selected goal is reviewed. At every visit, the patient is asked to make a new functional goal or continue working on an earlier goal with team members providing necessary recommendations. Outside of regular visits, there is frequent communication between providers and patients to fulfill other concerns. This goal-based, longitudinal and collaborative team approach shifts the focus away from pain and pain-related behavior towards functional restoration and independence.  

 

What is the role of PT and current barriers for PT in treating chronic pain

Apart from a multidisciplinary collaboration, chronic pain is addressable within physical therapy. However, many physical therapists perceive barriers and challenges implementing a biopsychosocial treatment model with their patients with chronic pain (5,6). There is often a feeling of insufficient training and skill using this novel approach, which requires a change in thinking from traditional biomedical intervention. In fact, ninety percent of providers, including psychologists, nurses and physicians do not have thorough training to properly address chronic pain (6). A recent survey of doctoral PT programs was found to have poor awareness of chronic pain intervention (7). Due to these issues, there is a sense of frustration, reluctance and dissatisfaction among PTs treating patients with chronic pain resulting in reliance on outdated practice with poor outcomes. 

Now that we appreciate the pitfalls of the current model of treatment, how can we improve our existing practice to address the critical needs of patients with chronic pain?  

 

Approaching this patient population in PT  

As chronic pain is multi-dimensional in terms of life impact (8), best management is achieved by using a multimodal approach (9). It can be challenging to address chronic pain issues within physical therapy, and it is not always clear where to start. Chronic pain patients can often feel frustrated by lack of progress using a traditional biomechanical approach to pain management. Feeling unprepared to work with the multifaceted nature of chronic pain, therapists may not be aware of methods to integrate a biopsychosocial model into their interventions (8). Additionally, physical therapists may feel that the psychosocial domain is outside their scope of practice and does not fit within the established professional role (4). Reframing concepts can answer the need to address both the behavioral and emotional sequelae of long-standing chronic pain that act as barriers to restoring function (7). This is where physical therapists and assistants have a great advantage over all health care professionals. We are perfectly positioned to help this refractory population due to our special skill of being educators and having ample one-on-one time with our patients. Our expectations will need some modification which is a simple enough thing to achieve life changing outcomes that are rewarding to both patient and clinician.  

So, how does evidence-based care look for high-impact chronic pain? There is such a strong need for improved interventions for chronic pain that the American Physical Therapy Association adopted guidelines and competencies in 2018 emphasizing the biopsychosocial model within a multidisciplinary model (10). Our first step is to educate ourselves that chronic pain comes more from the central nervous system with a de-emphasis on tissue damage and injury as the source of chronic pain. e. Reconceptualizing how the pain system works helps change pain beliefs, decreases fear of movement, and reduces catastrophization (11). We know gentle low-level exercise is great for improving function and addressing nociplastic (pain without the presence of tissue damage), nociceptive, and neuropathic pain. People who are in pain can be reluctant to move, so physical therapists can pair what we already know is beneficial alongside education using simple terms, images, examples, and metaphors (10). Valuable tools include questionnaires to identify pain beliefs such as the Pain Catastrophization Scale or the Tampa Scale of Kinesiophobia. Do not be afraid to address negative lifestyle behaviors that additionally sensitize the nervous system. Help integrate new supportive behaviors surrounding pain such as meditation, relaxed diaphragmatic breathing, and self-reassurance. Limit passive care and empower patients to address their own needs and minimize reliance on others (10). These skills work together to calm a sensitized nervous system to improve independent pain management and function. The last step is to coordinate care with your team. Share your experience with referring providers, coworkers, and other disciplines (11). Consider referring to an interdisciplinary pain clinic that can help support your excellent work and refer to other disciplines judiciously, but liberally.  

 

    This blog was meant to provide you a glimpse of how PT can play a critical role in restoring function of patients with chronic pain. But there is much more that needs to be done to update our skills and improve ourselves. If any help is needed, you have suggestions, or just want to talk or share, please reach out to Karnik Shah (kshah16@hfhs.org) &/or Andrea Sherman (asherma2@hfhs.org). 

 

 

Karnik Shah is a passionate and caring person, who enjoys treating patients with various musculoskeletal and neurological injuries. He specializes in treating patients with chronic pain syndrome. Karnik Shah graduated with a bachelor’s   degree in physical therapy from SBB college of Physiotherapy, Gujarat, India. He pursued his Master in Exercise Science from Oakland University, Michigan, USA. Furthermore, he completed his second master’s in public health with   focus on health behavior and health education. Karnik is curious and fascinated by how an individual’s behavior, attitude and beliefs can impact their health simultaneously considering the socio-demographic factor influencing one’s   health outcome. His passion for psychology pushed him to get certified as Cognitive Behavioral Therapist. He combines principles of behavioral health, psychology, and various manual therapy skills to improve the quality of lives of his   patients.

In his personal life, Karnik enjoys playing sports like cricket, pickleball and volleyball. He loves hiking and traveling to different places. To keep mental peace, he meditates every day and enjoys cooking for relaxation. He also loves reading books and enjoys history.

 

 

 

 

Andrea K. Sherman is an outpatient physical therapist who works closely with chronic pain patients and those with craniofacial pain. She was introduced to management of chronic pain while a PT student at Wayne State University in Detroit, MI. Andrea honed her skills and love for patients with chronic, refractory craniofacial pain while working for Michigan Head-Pain & Neurologic Institute in Ann Arbor, MI. After taking a position at Henry Ford Health, she has been grateful to continue learning methods to address and coordinate evidence-based care relating to individual with high-impact chronic pain as member of the multidisciplinary chronic pain clinic. Andrea enjoys knitting, all things outdoors, and adventures with her puppy, Pippa.

 

 

 

 

 

 

References

1. Department of Health and Human Services: National Pain Strategy: A Comprehensive Population Health Strategy for Pain. Available at: https://iprcc.nih.gov/docs/ HHSNational_Pain_Strategy.pdf Accessed on Dec 28th, 2022
2. Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin J Pain. 2002. 18:355-365
3. https://www.practicalpainmanagement.com/resources/practice-management/demise-multidisciplinary-pain-management-clinics 
4. Cowell, I., O'Sullivan, P., O'Sullivan, K., Poyton, R., McGregor, A., & Murtagh, G. (2018). Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: a qualitative study. Musculoskeletal Science and Practice, 38, 113-119.
5. Sanders, T., Foster, N. E., Bishop, A., & Ong, B. N. (2013). Biopsychosocial care and the physiotherapy encounter: physiotherapists’ accounts of back pain consultations. BMC musculoskeletal disorders, 14(1), 1-10.
6. Holopainen, R., Simpson, P., Piirainen, A., Karppinen, J., Schütze, R., Smith, A., ... & Kent, P. (2020). Physiotherapists' perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies Pain, 161(6), 1150-1168.
7. Bement, Marie K. Hoeger, and Kathleen A. Sluka. "The current state of physical therapy pain curricula in the United States: a faculty survey." The Journal of Pain 16.2 (2015): 144-152.
8. Caneiro, J. P., et al. "Process of change in pain-related fear: clinical insights from a single case report of persistent back pain managed with cognitive functional therapy." Journal of Orthopaedic & Sports Physical Therapy 47.9 (2017): 637-651.
9. Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet. 2021 May 29;397(10289):2082-2097. doi: 10.1016/S0140-6736(21)00393- PMID: 34062143. 
10. Louw A, Sluka KA, Nijs J, Courtney CA, Zimney K. Revisiting the Provision of Pain Neuroscience Education: An Adjunct Intervention for Patients but a Primary Focus of Clinician Education. J Orthop Sports Phys Ther. 2021 Feb;51(2):57-59. doi: 10.2519/jospt.2021.9804. Epub 2020 Oct 19. PMID: 33076759. 
11. Hernández-Sánchez S, Poveda-Pagán EJ, Toledo-Marhuenda JV, Lozano-Quijada C. Dealing with Chronic Pain: Tips to Teach Undergraduate Health Sciences Students. J Pain Res. 2022 Oct 18;15:3223-3232. doi: 10.2147/JPR.S377124. PMID: 36281308; PMCID: PMC9587724.
12. Hernández-Sánchez S, Poveda-Pagán EJ, Toledo-Marhuenda JV, Lozano-Quijada C. Dealing with Chronic Pain: Tips to Teach Undergraduate Health Sciences Students. J Pain Res. 2022 Oct 18;15:3223-3232. doi: 10.2147/JPR.S377124. PMID: 36281308; PMCID: PMC9587724