How do Exercise & Manual Therapy Fit Into a Less Active, Socially Distanced World?

By Jason DeCesari, PT, DPT, GCS, OCS

QAPD Clinical Coordinator, APTA Credentialed Clinical Instructor

When the new year turns over, we look forward to the coming year with great optimism. Many make resolutions to be more active, eat healthy, and change their lifestyle. This year one could argue that we have all made more lifestyle changes than any year prior, even if they weren’t by choice.

The outbreak of COVID-19 and the resultant response has changed the lives of people worldwide. We are spending more time inside, more time on the couch, and less time doing the things we love. While this has been a challenge for all of us, it is particularly concerning for older adults.

For Older Adults, COVID-19’s Activity Changes Could be Catastrophic

Many older adults have not ventured out of their homes in weeks or months for fear of contracting the novel coronavirus. They are having groceries delivered, medications picked up by family, and using telehealth for medical appointments.

They are choosing, for safety and the public good, to be isolated and likely sedentary. This change in lifestyle will impact every body system in a different way, the musculoskeletal system will be worse for the wear(or lack thereof). A 2010 study investigated the effects of bedrest on older adults and sarcopenia. It found that these “catabolic crises” could initiate a decline from which many older adults would not recover. In addition to muscle loss, inactivity can exacerbate joint pain, stiffness, and arthritis. A 2008 study of 3,613 women found that walking and leisure time physical activity had an inverse relationship with self-reported “arthritis.”

The results of these studies are no surprise, and we have all at some point said to a patient, “If you don’t use it, you lose it.” This may be the moment in history or at least our lifetimes that this quote is most pertinent.

Each physical therapist will have the opportunity to meet this new challenge and serve our communities.

A New Study Supports the Role of Physical Therapy in Management of Osteoarthritis of the Knee

In the spirit of finding the silver lining in a dark cloud, the evidence for the role of physical therapists in restoring function and controlling pain is growing. A study in the April New England Journal of Medicine speaks to physical therapists’ role in the management of osteoarthritis (OA) of the knee. This article compares physical therapy intervention, in this case, exercise and manual therapy, to glucocorticoid injection for the management of patients diagnosed with knee OA. The study looked at 156 patients with the primary outcome being the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The patients in the physical therapy group demonstrated scores 18.8 points lower than those in the glucocorticoid group. This is effectively 1/3 less pain and disability as measured by the WOMAC. The investigators also looked at a variety of secondary measures, including Global Rating of Change, Alternate Step Test, and Timed Up and Go. All showed positive trends for the physical therapy group.

An important question to ask when considering a study like this one is, “What does physical therapy mean in this study?” In this case, the therapy provided used a protocol outlined in a 2016 study that made a similar comparison between glucocorticoid injection and physical therapy. The protocol included manual therapy techniques directed at specifically identified deficits in each patient. The techniques were grade 3-4 mobilizations for knee extension, flexion, tibial internal/external rotation, etc. The exercise protocols included exercises such as terminal knee extension, quad sets with an extension mobilization, heel slides in supine with over-pressure, and LE stretching. These interventions were provided by orthopedic clinical specialists (OCS) and fellowship-trained clinicians. Guidance was provided for the clinical decision-making around the dosing and progression of exercise. At the heart of the program were manual interventions directed at specifically identified deficits to facilitate exercise. The manual therapy used to promote the activity that is the “cure.”

The implications of this study cannot be understated when considering the impact on the lives of patients with OA. The use of physical therapy as an intervention for the management of pain and disability can delay or eliminate the need for surgical intervention. This cannot only eliminate the acute effects of surgery but also limit unnecessary exposure to infection risk. Furthermore, the one-year cost of care related to knee OA in this study was similar, but a single surgery avoided can save thousands to an already strained healthcare system.

So Manual Therapy and Exercise are a Superpower, You Have to Use Them!

After reading the protocol above, two important points should stand out. First, the clinicians were experts and that can scare many clinicians away. Many of us have an impulse toward self-deprecation that says, “I’m not an expert, so I can’t get those outcomes.” This could not be further from the truth. While there is no doubt that the clinicians in this study are at the pinnacle of their field, the techniques they are using are ones that every one of us learned in our entry-level education. The difference is that they are confidently applied based on the identification of specific deficits.

Each physical therapist can elevate their evaluations, measure appropriately, and apply these techniques. Each of us not only can do this but has a responsibility to use our skills to attain these outcomes with our patients.

The second takeaway each physical therapist should glean is the need to consult the evidence and utilize available protocols. The clinicians in these studies are experts in every sense of the word but were humble enough to seek guidance and use a protocol that could guide their clinical decisions. Nearly every study comparing exercise vs. manual therapy combined with exercise has demonstrated the superiority of the latter.

Despite this, there are physical therapists who choose not to use/develop their manual skills or use them too seldom. As a profession, we enshrine the importance of evidence-based practice and each clinician has the responsibility to answer this call. Question each clinical decision you make, and decide if you are following the best available evidence or letting habit make your clinical decisions.

Be the Clinician the World Needs Now!

As we emerge from the COVID-19 pandemic and our patients seek the return to activity they desperately need, a call to action is in order. First, consult the evidence in the areas you treat and use the techniques we know will work. This may require that you add techniques to your toolbox and likely take some out. (There was a time that our field though that Ultrasound was a magic wand for all conditions.) That said, there are wide areas of deficit in the body of literature that will require we use less researched techniques. This is the place for things like expert opinion and clinical experience. As long as each clinician seeks and uses the best available evidence, we will be answering the call in the best way possible.

Second, each physical therapist who works with patients dealing with OA should use their manual skills and exercise prescription to manage pain and facilitate an increase in quality of life. This recent study outlines the need for physical therapists to help our patients avoid the need for injections and manage their pain and disability with a more effective and less invasive treatment strategy.  This will help these patients minimize the need for office visits, stave off physical decline, and return to the life they deserve.

The country and the world need each person to evaluate their skill set and help to rebuild as we being to move into the next phase of the pandemic response and into a new reality. Our interventions cannot only help the patients we treat but facilitate their participation in the broader recovery.