This podcast focuses on the current situation as it pertains to the effects of Covid on outpatient therapy services and the likely future impact. There have been a large number of webinars and presentations looking at the impact of Covid on therapy services in 2020, but this podcast focuses our attention to the here and now. One can only influence the future. The past is the past.
Managing COVID in the Outpatient Therapy Setting
Today’s podcast is titled Physical Therapy management of the Long Haul Covid patient and our guest is Gretchen Walsh. Gretchen is currently the Director of Clinical Excellence and Leadership for Alliance Physical Therapy Partners. Before we start talking about the PT management of Long Haul Covid patients or rather post-acute sequelae of SARS Covid 2 infected patients would you be so kind as to introduce yourself the listeners Gretchen.
I am licensed physical therapist. I received a Masters of Science in physical therapy from Grand Valley State University in 2003. And then I went on to receive a Doctor of physical therapy from the University of St. Augustine for Health Sciences in 2011. So, my passion for continuing learning has led me to advanced certifications in manual therapy MDT with the McKenzie Institute and trigger point dry needling. I’ve also have advanced training in public health and sports medicine to name a few. So these accomplishments have really allowed me to be a jack of all trades with my physical therapy practice. I’ve worked in a variety of settings including outpatient, acute care, Inpatient Rehab even on a little bit of Home Health and skilled nursing as well. And then I became Clinic Director for Advent physical therapy. Which is an alliance Physical Therapy company in the Grand Rapids Michigan area. I did that for 11 years prior to taking on my current role here with Alliance in early 2019. I do still see patients on a regular basis at Advent physical therapy as well as maintain a compliance role and then beyond my work with Alliance. I’m also adjunct faculty at Grand Valley State University and their physical therapy department. I’ve done that since 2012 and I’m an education reviewer for the American Physical Therapy associations Michigan chapter and that’s been since 2016. In my current role, I’m responsible for overseeing the program for the clinical excellence and leadership company-wide. So along the way I’ve also had a pleasure of having a primary role in the implementation of several programs that really support our patients and the clinicians most recently Telehealth and what we’ll be discussing today, which is our Covid recovery program.
Before we dive into the weeds as it pertains to talking about the very specific recovery programs in the management of Covid by therapists. I’d like to understand a little bit more about what we mean by to long-haul Covid as I feel that it can be subcategorized almost when it pertains to therapy. Would you perhaps shed some light on that and you do you agree with the idea that there isn’t really a specific set of symptoms or type of patient.
Yes. Definitely there, you know for what we’ve done in our program. We’ve really divided it into I would say about three subcategories. The first is really those that have been generally deconditioned due to quarantining or stay-at-home orders that have occurred. I’ll give you an example, I saw a patient back in July for physical therapy, they had some falls happening. They were having balance troubles and general weakness, and it was essentially because they were homebound from mid-March to June. This patient was a 70 something year old female and she normally would go to a pool and do aerobic exercises. Because that pool had remained closed for months she was experiencing a lot of weakness and balance troubles and essentially had some falls that brought her in for physical therapy. So that’s one group to consider and then then there are those that you might traditionally think of those that have been affected and they’ve recovered but again, they have some weakness or some immobility that occurred due to lack of exercise and activity when they were recovering. Those folks still potentially could need physical therapy and receive our guidance for how to safely return back to work for a physical job or perhaps they’re wanting to return back to exercise or a fitness level that they were doing prior to coming down with covid-19 and PT can have an impact there certainly. Then the third category is really those that are infected, but they continue to have those symptoms after the actual infection has resolved and and these are occurring for an extended period of time. So, these folks they might be experiencing that multi-system involvement. Those are the ones we would categories as that PASC. So as Richard you had previously mentioned, the acronym is stands for Post Acute Sequelae of SARS coronavirus infection, so it doesn’t exactly roll off the tongue, but that’s what PASC is. The National Institutes of Health they’re just defining that as a person who’s been infected with the covid-19 virus and they continue to exhibit those symptoms for 28 days or longer. So that’s where that definition is coming from and often that lay term might be considered you might hear the terms long covid or long haulers and that’s referring to that PASC,
I challenge anyone to say post a post-acute sequelae of SARS Covid 2 when they’re drunk! I think what’s interesting about the kind of the subcategories that you’ve described even though they aren’t technically defined in the literature is I really don’t think people think about the indirect effects of Covid. So for instance and you’re my mother is in her 80s, and I’ve seen a significant decline in her just general endurance and mobility since the onset of Covid as a direct result of just being in quarantine, essentially and I’m sure that’s the same for the majority of elderly. Oh, yeah. Absolutely. I mean we’ve seen number of patients, as you said maybe they weren’t infected themselves, but, related to the issues of having to be that homebound or quarantining themselves. It’s really had quite an impact.
It’s interesting how our understanding of Covid has changed. I know that as a company, like many other PT providers, we initially thought that the primary symptoms that we would be treating is deconditioning related to respiratory difficulties, but that’s really changed hasn’t it. I believe now if correct that really Covid can affect multiple systems. Is that true of PASC patients?
Yes, definitely. There’s multi-system involvement. It’s going to vary person to person and that’s where I think it can be tricky because there might be some that are experiencing more what you might think of that cardiovascular system impact respiratory and certainly some musculoskeletal but then there are those that are having issues with renal even dermatological, neurological and psychiatric is also another big body system area of impact that’s happening for these post Covid patients.
It’s not just necessarily one system is it? One patient can have multiple systems. So it’s not as if one patient will present with cardiovascular another present with MSK another present with neurological. It can be multi-system. Correct even within one patient?
Exactly. when you’re getting into the common symptoms or complaints for example, you’re seeing it might be fatigue, short of breath. They may also be getting those muscle aches and pains, joint pains. They could have difficulty thinking they might state, ‘I feel like I have brain fog’, memory troubles, it might be headaches. Some of them are getting sleeping disorders and they’re getting even intermittent fevers much beyond when the actual infection was active. Additionally there’s even GI issues and of course the anxiety and depression even PTSD is quite relevant symptoms in this in this population,
Even for our musculoskeletal conditions. I believe that probably over 60 percent of patients have a psychosocial component that we have to address as therapists. But I’d imagine with these Long Haul Covid patients, it’s probably the majority probably have a psychosocial component, even just based off the anxiety and stress that it’s caused. Yes.
Yeah exactly. I mean, we’ve all had to deal with the stressors from the pandemic and it’s going to have an impact and unfortunately, it doesn’t always clear out as the same consistent symptoms from person to person.
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Welcome back to Agile&Me a physical therapy leadership podcast. If we focus on what therapy can help, what we can do in the Outpatient Clinic. What do you believe are the common symptoms and functional limitations that we can assist with, what long-haul Covid patients do you think that we can help?
Definitely those that are having general poor endurance, fatigue and shortness of breath. Muscle aches and joint pains are also certainly our area of expertise. Then when you get into more the neurological where you’re seeing the balance troubles there could be gait disturbance, difficulty walking, anything related to that. Then kind of looking more big picture. There are those that are really struggling to get back to work and perhaps they have a physical job or even just the endurance of sitting at your desk all day for 8 hours that can really be a challenge for some of these folks. So we can be assisting and providing support in those areas. Certainly.
I found it interesting and surprising the degree of fatigue that these patients can experience over a long period of time and they have to pace themselves physically, don’t they, because it’s remarkable how quickly they tire. Have you found that?
Yes, absolutely. You may find that even doing some of your simple and will probably touch upon this later I’m assuming, but some of the functional test that you may be doing, six-minute Walk test for example, it may not be able to be completed or it may be something where they’re having to do a graded return-to-work perhaps they’re starting at half days and working up to six hours and then slowly working towards eight hours. So, you know, it definitely has had a big impact,
We mentioned the idea that in the beginning we thought it was primarily respiratory in nature, that we would be addressing. But is there any other changes in our understanding as times gone on, since the early days of the pandemic, as it pertains to the post Covid patient presentation?
Sure. Yeah, as you mentioned the focus additionally it was more on cardiopulmonary systems. I can think back to some of the initial images that came through with Covid. It was either the images of the spear the infection itself or it was lungs, you know pictures of lungs. Everything was lungs, lungs, lungs and there was the awareness of if a patient had been an ICU that they might have things such as neurological or musculoskeletal concerns beyond their hospitalization. Now we know so much more. We know that there’s that multi-system involvement as we’ve discussed and we also know that it’s not just those that have been in ICU that are experiencing these lasting symptoms. So it could be anyone, a common age range is even the females that are ages 30 to 60 are experiencing this. So those that are not necessarily in that typical population where you may think, oh they had comorbidities, they had a lot going on with their systems prior to Covid and they ended up in ICU. They got that infection and that makes sense. But here, what we’re really seeing is that anyone can have these lasting symptoms
What figures I’ve seen statistics. I was surprised at the number of patients that exhibit symptoms over extended period of time see the severity is very different and based on that number, I’m even more surprised that we aren’t being referred more patients for post Covid or Covid type recovery because there’s got to be a lot of people out there that that are experiencing functional limitations and can benefit from physical therapy that aren’t just aren’t being referred. Do you believe that’s true as well?
Yes, absolutely. I can guarantee you this is an underserved population. I’ve seen stats, it varies a little bit. I’ve seen anywhere from 10 to 35 percent of individuals that had Covid infection have had lasting symptoms. So, if you look at those stats alone, you know, there’s a high population out there that are still struggling.
Before we talk about the assessment and treatment of PASC, I’d like to understand if you believe there are precautions we need to put in place for treating this patient population?
As far as precautions go, yes, certainly. You want to think of your standard PPE that you’re going to be doing for all your patience right now certainly and you want to make sure that you have on point your vitals and you’re doing your vital monitoring that’s going to be really essential for this population. That’s why I do really see the value in actually truly building a program to support this so that it’s a formalized process and all your clinicians are on board and really have the information and feel confident and comfortable with what they should be doing as far as assessing and treating these PAC patients.
Moving on to the actual management of this patient population. What should be included in the subjective section of an evaluation that perhaps is either not necessarily other types of patients or or not so much a focus of the evaluation. So, from a subjective perspective what’s important do you believe?
Obviously identifying what their prior level of function is, so you can establish those realistic goals. You definitely want to know if they’ve been hospitalized, have they been in ICU, how many days, were they on a ventilator any respiratory support they may have had. Any complicating factors that could have occurred whether they were hospitalized or not. They are seeing myocardial infarctions, myocarditis, even strokes occurring in some of these patients. So, you want to know their background, their history and what their experience has been throughout the process. Then from a medication perspective, it’s really important to know if they’re on beta blockers or any cardiac meds that could affect their ability to be using heart rate as an indicator or for us to be using heart rate as a monitor and a measurement for their physical activity. So that may not be able to be utilized to determine their physical activity tolerance if they are on those type of medication. So those are important to note. Anticoagulants that’s also important to note as well as far as meds. You want to be monitoring their cardiac risk factors and assessing what’s their support system and including their living situation.
Residual symptoms, we’ve already gone through what they are the common ones. We want to know you know what those multi-system involvements may be looking like for this particular individual. Comorbidities, that’s obviously something were typically doing anyways, but particularly important would be the chronic respiratory disease, cardiovascular disease, hypertension, diabetes, cancer and autoimmune diseases should be considered as well for these folks. It’s really important in this group to be performing cognition and mental health screening. Many of these folks are having memory troubles anxiety, depression, PTSD as we mentioned. So it’s really important that they are screening for these cognition and mental health concerns that could be occurring.
The point around comorbidities I think Is important. Obviously with every subjective were asking about your relevant medical history and current comorbidities, but obviously with this patient population those that we’re probably seeing are more likely to have relevant and significant comorbidities because they are more susceptible in the first place. Is that right?
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Welcome back to Agile&Me, a physical therapy leadership podcast, With an evaluation is obviously an objective component that includes functional test. With regards to the objectives section, is there anything really different and what kind of functional test you think are perhaps most relevant for this patient population?
I think vital monitoring, as I mentioned previously, is really important. Doing heart rate monitoring oxygen saturation, that’s really important to get in monitor for these patients. We have to appreciate the fact that it’s actually been found that with Covid-19 you could not necessarily be short of breath with physical activity, but you might still be experiencing O2 desaturation. So that’s a really important factor to be considering with your patients for monitoring. Respiratory rate, BP and rate perceived exertion, those are all important. Looking at observation, coughing patterns and their ability to clear. Breathing patterns is always essential. You want to do a full system analysis. So you’re going to look orthopedically, are they having any restrictions with their joints,range of motion and flexibility wise. If they have had a hospitalization for example. Neurologic is, as mentioned, can be a important component. So, you’re wanting to see dynamic balance standing balance their gait quality. What is their fall risk? In getting those bass lines is important. Also, for walking tolerance and important to note as well whether or not they’re on supplemental oxygen. Because that’s a great goal for them to be getting off any supplemental oxygen as well. And then I think you mentioned functional test, too. We are looking at quality of life and doing quality of life survey. So, we use the short form 36 for that. That’s the sf-36. That one’s a gold standard ‘bread-and-butter’ really great quality of life survey. There is a Covid-19 specific impact on quality of life scale that is out there. It’s in research trials right now. It hasn’t been validated. It could be quality of life measure to consider for these patients. Then as far as specific functional test your six-minute walk test, you know, that’s a gold standard for submaximal exercise testing. The issue with that is is it might not be feasible depending on the space and your Outpatient Clinic so you do want to consider that, but you need to be able to maintain social distancing and the time to complete it. So that’s something to consider. So others that I think are really great options would be a 2-minute step test. So, this is also good for telehealth because it can be easily replicated in the home. So, the instructions are quite simple and the patient will remain visible so it can be done in a confined space. If you’re more in an in-clinic setting or they can be still remain visible on a video screen if you’re doing it through telehealth so that the therapist can monitor that test remotely. Then the one-minute sit-to-stand test, that’s another great option for confined spaces or over Telehealth, so that could also be considered. Then the short physical performance battery. That’s a good test if you want to look at several components. So it over it reviews a patient’s ability to do different balance activities, looks at gate speed and sit to stands as well. This one would definitely be for in clinic only but it is a nice option because it’s for 10 minutes or less.
Moving on to the treatment component. Obviously, the treatment is dependent upon the systems that are significantly involved. What would be the typical components would you say, if there are typical protocols or components of a treatment of a PASC patient?
You’re definitely going to want to be addressing large group muscle-strengthening certainly their functional mobility, gait and balance. troubles. You want to look at core strengthening postures, especially any time that it’s related to anyone who’s generally deconditioned or has breathing troubles. Endurance, energy conservation is going to be huge for this group and providing education on that. Breathing techniques, so it might be looking at paced breathing, pursed lip breathing, airway clearance different positioning techniques. Those are all options as well. You want to be educating on risk factors? We’ve talked about the comorbidities already, Smoking cessation and weight loss, these are going to be huge to be providing education for this population. Then looking at aerobic training. So, you really need these patients to be looking at least three to seven days a week of some sort of bouts of aerobic training. Even if it has to be short, you can be calculating their max heart rate. You can look at what correct ranges they may need to start it. They may be so deconditioned you have to start at 40 percent of their maximal heart rate, but then slowly over time they can be working up to more that 60 to 80%, what we’d be looking for in a more healthy adult population. So that would be I would say as a typical treatment scenario the components you’d want to be looking at.
You mentioned monitoring certain body systems during evaluation and treatment, what equipment do clinics need to be able to successfully treat these patients in a safe manner would you say?
It really doesn’t take a lot. I mean definitely pulse ox is important and perhaps blood pressure cuff. Having a rate of perceived exertion scale is really critical and that’s something that’s good to be providing these patients as well. So they can do self-monitoring. But really it doesn’t take a lot just
From a practical perspective. We always have to get paid for our services. Which ICD-10 codes need to be used when building these patients? Have you worked out what the secret sauce is for getting payers to pay for these Services?
Well, as you can imagine, we’ve already discussed that it’s very patient dependent and a wide variety, but there are you know, common codes certainly that could be used for this subset of patients. So, the common ones that I would say are really typically well reimbursed would be the general weakness, shortness of breath and difficulty walking, And more of those neural based codes such as unsteady on your feet, lack of coordination, gait abnormalities and then also adding in any appropriate comorbidities. That’s also critical, as that could impact care. So those would be important. I would say diagnostic codes that would be related to those ICD-10 codes for billing.
You’ve mentioned telehealth a couple of times specific to the Long Haul Covid / PASC page. When do you think it’s appropriate to see these types of patients using telehealth instead of a hybrid model or in bricks-and-mortar clinics would you say?
Sure, so if a patient is tested positive but is not symptomatic the treatment really telehealth could start immediately. Or let’s say they’re just quarantining because there’s a family member that has tested positive, they can do telehealth at any time. And then if the patient has mild symptoms, then the treatment should start or resume once they’ve been cleared from their physician which is fairly quickly. Then you know for those that have more of those long covid symptoms, they really should be self-monitoring their vitals and having a patient do that self-monitoring during physical activity and they can have a family member. assist. So as long as they have that ability to do that self-monitoring of vitals and making sure that can be performed in a safe manner then even that population can certainly be seen for telehealth as well.
I often wonder whether telehealth might even be better for patients in respect of this group. I’m sure a significant proportion is group. It’s probably anxious about going into public spaces or areas where there are other people because even if they are no longer symptomatic. I’m sure there must be apprehension still.
Yeah, certainly and one thing that is interesting when you look at the research. There’s some case studies coming out, a lot of it’s more pertaining to the hospital setting, but there was just in February of 2021 prospective study that was from the Journal of Physical Medicine and Rehabilitation and it looked at outcomes for Covid-19 recovery programs for patients that had been hospitalized with Covid-19 infection in New York City and those that still had symptoms upon leaving the hospital. And they did evaluate a virtual program and found that it led to improved strength gains and cardiopulmonary endurance when compared to no intervention at all. Then they also determined that was beneficial compared to doing independent exercise or no exercise. So, we do know at least from some initial research that the outcomes are promising for virtual care and addressing this population.
Welcome back to Agile&Me, a physical therapy leadership podcast. For clinicians, is there specific knowledge or training that they require or need to be able to manage these patients do believe?
I think that they do need to load up on their cardiac and pulmonaryknowledge and certainly be more in tune with what is current with Covid-19 and the PASC diagnosis certainly. But, they have to have that appreciation and understanding that we’re performing physical therapy for Cardiac and Pulmonary conditions not cardiac rehab. Sometimes that can be confusing. So, providing clinicians that information can be really helpful and just brushing up on the typical, the biomonitoring, pre-post activity which should already be familiar with and the defining of what special tests or functional tests or ideal. Here at Alliance, we’ve really have a defined Covid recovery program with Education and Training for our physical therapist, and I do feel like that’s been quite helpful in ensuring that they are prepared. As well as we have a modified phased return for physical activity protocol that we’ve been utilizing. This is a nice piece that was published in the British Medical Journal in January of this year and it addresses physical activity or return to physical activity after having Covid-19. So. the protocol that we’ve developed and kind of modified from this journal article is really helpful because it provides guidance and some best practices to our clinicians so that they can follow it. It’s also a nice piece for patients as well because they can look at where they may be starting with in the phases for return to physical activity and then what the goal markers are and expectations to kind of move on to each phase. So that’s a really nice visual that we can provide. Then there are also online continuing education courses certainly that are out there you do utilize MedBridge for example. They can be a great resource and APTA has lots of resources as well that could be quite helpful.
It’s really remarkable the speed not only of the vaccine development but also the speed of research being published and good quality research in all the facets of Covid. So, it’s nice to have that evidence-based practice. Are there any case studies published pertaining or either case studies or research literature pertaining specifically to PT management interventions of Covid patients that you know of?
As I mentioned, most of them are in the hospital setting so far or those that have been in ICU. So as far as the PASC goes it is limited at this point. The NIH, they have recognized this as the diagnosis and gave it that definition that we discussed previously, and the medical community is continuing to understand and realize that this is a factor and is a real concerns and issues for these patients on going. So it’ll spark more research to come. Specific to more in the outpatient, or as I mentioned that virtual setting, some of the prospective studies are coming out such as the virtual program to address Covid-19 patients as I mentioned previously.
Finally, the podcast series is directed obviously at leaders, clinic owners, clinic directors and aspiring leaders. The Long Haul Covid PASC patients I believe is really, for want of a better term, another subspecialty that I think outpatient therapist can provide to patient population. How do you feel practices can promote such a program. What methods do think are appropriate and what’s been done by Alliance and other companies that you’ve seen?
First and foremost, it’s important to establish a true Covid recovery program. It’s critical because you need your clinical teams to be on board. You need them to understand the nature of the Covid-19 sequelae. They need to feel confident in their skill set when they’re treating these type of patients and that way they can actually promote the service. Then focusing on outreach to area physicians and also direct to patients I think is really critical with this program. They need to know that physical therapy is a service that should be considered for any recovering Covid-19 patient with ongoing symptoms. So, the more we can promote that awareness I think more patients will be able to be served by these type of programs.
Before we leave any final thoughts ideas for PT leaders as it pertains to the management of this type of patient population?
I would just say that, Physical Therapy definitely has a place at the table in treating all these Covid-19 scenarios and the more that we are dedicated to promoting our services and training our clinicians in order to feel comfortable with seeing these type of patients the better off we’ll be.
Thank you for spending time today Gretchen talking about Covid recovery programs and management of this patient population. I really appreciated your knowledge, insight and hopefully the listeners have gleaned some information that will help them take care of this patient population. Thank you.
Thank you. I appreciate you having me this podcast was brought to you by Alliance Physical Therapy Partners and agile virtual care for more information.
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