Redefining Physical Therapy in the Time of COVID: Time for Innovation

Change is often driven by necessity, whether due to a crisis or a feeling of dissatisfaction. During times of duress, current structures are challenged and pushed leading to innovation or failure. During the 1918 Pandemic, many of our current established hygienic principles were developed during that era. At that time no antibiotics or vaccines existed, so the primary control efforts depended on pharmacological interventions such as isolation, good personal hygiene, the use of quarantine, disinfectants, and limiting public gatherings(1). Previously communal cups were used at wells where everyone would use the same utensils. The pandemic created a systemic change in behaviors that are now standard in today’s hygienic practices. 
 
As a result of COVID19 companies have been forced to restructure or sink. The most evident has been for companies to implement work from home principles (Twitter, Facebook, Google, etc.), transitioning to video conferences and education. We clearly have a long way to progress to create a seamless virtual system, but this innovation was essential in maintaining a basic business flow. Manufacturing companies have restructured to focus on health care efforts, whether transitioning from beer production to hand sanitizers (Cortland Beer), or car manufacturers transitioning to various health care needs (2). In health care, the focus was on reducing contact (developing contact tracing methods), maintaining essential structures, upgrading systems for an increase in ICU and the number of ventilators, and attempting to educate the public on a clear response for mitigating the disease. Clearly certain countries and regions of the United States have been more or less successful in reducing the rate of transmission. 
 
With the drive for innovation and restructuring across various sectors, where is this happening in Physical Therapy?  In the initial response, certain hospitals deemed Physical Therapists as non-essential, focusing on nursing and medical needs prior. But once a patient is stabilized, how can they return home if they physically are unable to get out of bed? The evidence also clearly indicates that early mobility and exercise decrease not only length of stay but improves patient outcomes and in 2013 John Hopkins published a study demonstrating this clearly (3). The evidence of improved outcomes with prone positioning (lying on the stomach) hit the COVID19 market and all of a sudden the need for PTs was once again necessary for reducing length of stay and improving recovery times(4).  Outpatient therapy meanwhile transitioned to telemedicine or just held off on seeing patients. Telemedicine is not a new structure, it has existed for years, however, due to low reimbursement (basically non-existent except in private pay or rural areas) few clinics saw it as a good investment. Yet across the healthcare field the need for cheaper innovative solutions to providing care and decreasing the burden of care delivery on patients is essential. The slow transitions and adaptations to new health care solutions are frustrating. COVID19 has at least (yet unfortunately due to the health crisis) created an acceleration to adopting this model. Hopefully, these systems will stay in place post-COVID19 world. 
 
So what else is out there? How has PT changed in the last 50years? Medicine has clearly grown in leaps and bounds, but PTs while we pride ourselves in the fact that we are a “hands-on” medical service, that “we” will always be needed- that doesn’t mean we should sit on our stable pedestal and not push and accelerate innovation within our field. Since the implementation of our Doctoral degree, few changes have occurred within the field of rehabilitation. Yes, we get to see fancy new technologies especially in neuro-rehabilitation with the development of exoskeletons, various biofeedback technologies, virtual reality etc, but our structure remains the same. Patients either get seen by us on a surgical unit, or in an outpatient clinic. We schedule them at 3x/week for x6-8 weeks, and many times we are seeing these patients after 4-6months of dealing with pain or disability. The slow response of our health care system is not entirely our burden to bear, but we should be advocating for our patients and representing the voices of frustrations. 
 
One innovative solution that was implemented by the US military was to place PTs in a role of primary care providers (5). The study indicated that PTs were found to be and efficient and effective method of treating patients with musculoskeletal (msk) impairments. If a patient came in to see their PCP and the PCP deemed that it was an msk issue the patient could immediately see a PT and the PT could focus not only on the assessment (reducing the time/burden on the PCP allowing them to focus on medical procedures/interventions) but also on recovery. This is a fantastic example of the seamless interconnection between various practitioners for the overall improvement and quality of care for the patient. This model could easily be implemented in various systems across the US- unfortunately insurances play a role in limiting direct access (despite legislation in nearly all 50states allowing some degree of direct access). We need policymakers and major health systems to implement these cost-reducing quality improvement measures. 
 
Another solution that can help with the COVID19 response, is advocating for having PTs in ERs much like in Australia (6). Much like how a PT can be placed in a PCP office, PTs are excellent at screening patients for various msk injuries and can help triaging patients in an ER especially when the focus is on COVID. Patients with msk injuries will still present to the ED/ER and PTs can assist with screening and determine whether patients may need further imaging etc. As a clinician, I have had the opportunity to work with EDs, primarily in recommending discharges, but I have often performed musculoskeletal assessments in addition to mobility assessments. I can immediately start the patient on tailored exercises or education with managing their pain beyond that of just pain medication. Patients find that extremely valuable and it kick starts their recovery reducing disease burden but also reducing further cost of care. 
 
I have also worked at a hospital where they will schedule a patients discharge with a direct referral to an outpatient clinic in order to kickstart their recovery and reduce delay in transitioning to outpatient PT. The seamless collaboration across not only practitioners but also establishments improves quality, reduces costs, and improves patient outcomes. With the use of electronic health records and instant communication we should be seeing more solutions for collaboration and speed with transitions between care delivery models, yet the process is slow tedious and often requires extra work. These innovations should become normalized rather than the exception to the rule. With COVID19 burdening our healthcare system, we need more innovation, more seamless collaboration, and to reduce the burden of care delivery on the patient. 
 
References:

  1. CDC. 1918 Commemoration. https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/1918-pandemic-history.htm. Mar 21; 2019.
  2. Harper, J. Coronavirus: Carmakers Answers Please to Make Medical Supplies. https://www.bbc.com/news/business-51956880. BBC. Mar 21; 2020.
  3. Hoyer, E et al. Promoting Mobility and Reducing Length of Stay in Hospitalized General Medicine Patients: A Quality Improvement Project. https://www.journalofhospitalmedicine.com/jhospmed/article/127958/promoting-mobility-and-reducing-los. J Hosp Med. May 11; 2016.
  4. Guerin, C et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. https://www.nejm.org/doi/full/10.1056/NEJMoa1214103. N Eng J Med. Jun 6; 2013.
  5. McGill, T. Effectiveness of Physical Therapists Serving as Primary Care Musculoskeletal Providers as Compared to Family Practice Providers in a Deployed Combat Location: A Retrospective Medical Chart Review. https://academic.oup.com/milmed/article/178/10/1115/4352279. Military Medicine. Oct 01; 2013.
  6. APTA. Study: Even in After-Hours Settings, Seeing a Pt First for Msk Conditions in the Emergency Department Saves Time Reduces Opioid Prescriptions. https://www.apta.org/news/2020/03/11/study-even-in-after-hours-settings-seeing-a-pt-first-for-msk-conditions-in-the-emergency-department-saves-time-reduces-opioid-prescriptions. APTA. Mar 11; 2020.