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Some depend on in-person physical care to keep pain in check – the pandemic changed that

The pandemic has forced many physical therapists to work with patients online instead of at clinics.  (Shutterstock)
The pandemic has forced many physical therapists to work with patients online instead of at clinics. (Shutterstock)
By Amanda Loudin For the Washington Post

Last summer while out on a bike ride, 35-year-old Andrew Bernstein of Boulder, Colorado, was hit by a van that knocked him off the road and kept on going. A passing driver spotted Bernstein lying, unmoving, in a ditch and called 911.

Bernstein’s injuries were life-threatening. After multiple surgeries, 10 weeks recovering in a hospital and more than three weeks in inpatient rehab, Bernstein has spent the better part of every week since then working with a number of practitioners to help him progress to where he is today – in a wheelchair and walking with the assistance of a full-length leg brace and crutches.

But almost all of that effort came to a halt with the coronavirus pandemic in March, and all of his physical therapy facilities either closed or dramatically reduced their patient contact.

“I typically worked with a variety of therapists nine or 10 times a week at four different facilities,” Bernstein says. He was given a home-based plan, but “the disruptions to my therapies were challenging. It was frustrating to do without supervision because my condition changes from one week to the next, something my therapists might notice even if I don’t.”

Like Bernstein, thousands of athletes or post-surgical patients have missed physical therapy – or other types of body work – important to their health because of the pandemic. Physical therapy, massage and chiropractic treatments are regularly used by millions of Americans, according to various estimates, to keep chronic pain at bay, make progress with injury or help ensure that their muscles, tendons and ligaments stay in top shape.

Depending on the state, some patients might now be returning to reopened practitioners’ offices, but many still cannot. Others may have resumed therapy but have since seen their therapists have to shut down a second time. Bernstein, for instance, has recently been able to return to his normal schedule at his various reopened facilities.

Jason Beneciuk, assistant professor in the department of physical therapy at the University of Florida, says the effect of missed physical therapies depends on the patient’s situation.

“If (someone is) post-surgical and missing therapy, the fallout can be severe,” he says. “Even if not a surgical patient, for musculoskeletal issues, progress often depends on engaging with your therapist.”

Beneciuk co-wrote a study that said musculoskeletal pain is a “prevalent and costly health condition with far-reaching public health consequences, including chronic pain, disability and opioid-related addiction.” The study concluded that non-pharmacological treatment, such as physical therapy, should be a front-line approach for musculoskeletal pain – exactly what many patients are missing or have missed because of the pandemic.

Trent Nessler, a physical therapist and national director of sports innovation at sports medicine provider Select Medical in College Grove, Tenn., says for patients who were caught just post-surgery when many health care-related facilities shut down, the concern is for chronic pain and permanent range of motion loss.

“If you’ve got someone who just came off an ACL replacement (in the knee), for instance, the first 30 days post-surgery are critical,” he says. “If they don’t get their range of motion back then, they may never get it.”

Left without access to their regular hands-on therapies, many patients have or are trying to bridge the gap at home. Sometimes this involves telehealth appointments, which might or might not be effective.

“A lot of that depends on the therapist, the patient and their relationship,” Nessler says. “However, my obligation to a patient is ultimately to teach them to self-manage so that they never have to come back into the office.”

Patients who are not in the immediate post-surgery category can have an easier time getting better at home, but it won’t be as fast as in-office body work visits. “There are many great tools out there today … such as percussion guns, therapy bands and vibrating rollers,” Nessler says. “It may not be 100% as effective as in-person care, but it might get you 80% of the way there.”

A recent study of the effectiveness of hands-on PT versus internet-based exercise training for patients with knee osteoarthritis suggested working at home can be effective.

“The data isn’t as strong for therapies like massage, ultrasound or manual work as exercise-based physical therapy, which can be effectively taught via the internet,” says study co-author Kelli Allen, research professor of medicine at the University of North Carolina. “Also, aspects of other therapies typically done during in-person visits, like massaging sore joints or muscles, can be done at home.”

A few weeks ago, Latoya Shauntay Snell, a 34-year-old Brooklyn-based athlete who suffers from a herniated disk, sciatica and endometriosis, had her first massage session since February and says she felt the consequences of missing so many. Until the pandemic hit, she’d had weekly hands-on treatments for her pain, including massage, cupping and infrared therapy. “I’ve been in a world of pain,” she says. “There are just certain things a foam roller (at home) can’t do.”

Snell remained in regular video contact with her physical therapist over the past five months, and he guided her in self-massage. Snell also added in more yoga to help her body loosen up. But she found it difficult to motivate herself for her usual runs, strength-training sessions and bike riding despite her pain.

“The hardest part has been remaining consistent when you’re in pain,” she says.

Part of hands-on therapy’s benefit, Nessler says, is the psychological component. “It feels good to have that physical contact and manipulation, which changes perceptions of pain,” he says. “Hopefully moving forward, we can be successful with a mix and match of in-person and telehealth approaches.”

If there is a silver lining in this for people needing physical therapy, it’s that the remote model has been tested and expanded more swiftly than anyone expected, which might lead to improvements going forward.

“There haven’t been many studies on the robustness of telehealth, but there’s no reason to think it can’t work in many situations,” Allen says, whatever happens with the pandemic and beyond. “Now is the time to evaluate approaches and make changes for the future.”

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