Dr. Marilyn Moffat

[JUDITH MEER, HOST] Thank you for joining us today. I am here with Dr. Marilyn Moffat, the NYU, an NYU professor of physical therapy, as well as the former president of the American Physical Therapy Association and of the World Confederation for Physical Therapy. Dr. Moffat, thank you so much for taking the time to join us today. I really, really appreciate it.

[MARILYN MOFFAT] It's my pleasure.

[MEER] So my first question is, you've been a physical therapist yourself for over 40 years, you have worked with clients, patients, clinicians, students all around the globe. You've coordinated efforts to develop international guidelines and standards for physical therapy. And I'm curious to hear from you where you see the role of physical therapy, both during and after, after this pandemic.

[MOFFAT] You know, it's really an interesting sort of phenomenon. As I said, it's something incredibly unique to most individuals that are alive today. We have lived through other kinds of epidemics in our lifetime. I mean, I can remember the very tail end of the polio era when again, children were becoming paralyzed in the summer months and some surviving with incredible disabilities, some surviving with minimal disabilities, and others succumbing to the disease. This is obviously incredible in terms of its onset, not only the rapidity, but also the incredible numbers of individuals around the world that have been totally affected by COVID-19. And again, having no basis for treatment, and having to sort of grapple from the very beginning stages of how to manage these individuals, from those with the mildest to no symptoms to all the way to the other end of the spectrum. And that's what is certainly challenging everybody in every kind of healthcare arena today.

Physical therapists have a huge role in the management of these patients. Not only those who are on the frontlines in ICU and acute care hospitals, in nursing homes and other rehab types of facilities in terms of helping with the management of patients with COVID-19. But also the things that are going to be needed in the post COVID-19 environment for the management of patients who survived the respirator onset and have been able to get out of hospitals, after being on days, weeks of bedrest, and all the concomitant problems that are associated with the virus in terms of respiratory and cardiac and neurological and you name it, and almost every system has potentially been affected by the virus. So physical therapists are going to have to play a huge role in helping to get these people back to the lifestyles to which they have been accustomed, and again, can enable them to assimilate back into society.

[MEER]  So you make a really good point there about COVID-19 affecting sort of all systems of the body and from what I've been reading and speaking to my colleagues about, we know that there's some residual damage happening both to the heart and the lungs, among a couple other things from this virus. So assume someone's no longer in a hospital setting, thank goodness they've they've returned home and they find they're still struggling physically. What sort of tests would an outpatient physical therapist want to do to make sure they're creating an appropriate exercise regimen for that person? Or rather, as a patient, what would I look for to know that I'm getting the best possible care from my from my physical therapist?

[MOFFAT] Well, you'll probably have to go back a little bit and determine that it's not just the heart and the lungs that have been affected in these patients who have COVID-19. Certainly, I indicated the other systems but then you also have to look at the effects of bedrest. Now, we know they're doing interesting things and in ICUs they're proning patients on vents in order to increase their aeration and doing as much movement as possible. But when you've got that many patients needing such acute care, getting them moving and keeping them moving during this period of time becomes increasingly difficult in terms of use of manpower resources.

So if you look at some of the data about what happens with bedrest, I mean, physical therapists are going to have a huge role to play from multiple systems. I mean, we know that when someone is in bed, the functional decline that happens with immobility is incredible. We know that, loss of, they get loss of independence, inability to ambulate, their inability to do their activities of daily living. We also know that depending on the degree of fitness, for every week of bedrest, and this is just in again, normal aging populations, as opposed to those with COVID-19, it can take up to three months to recover. 10 days a bedrest can promote a decline in muscle mass, muscle strains, physical function. So we're dealing with a multiplicity of systems.

So when you asked me what kind of tests physical therapists should be doing, it's going to have to be tests address more than just the cardiovascular pulmonary system. So if I look at the sort of categories of tests and measures that we as physical therapists do, I would certainly hone in on a test of aerobic capacity. And we have simple functional tests that we can do in clinic environments that don't require a lot of equipment. I mean, we obviously need to take heart rate and blood pressure. And we need to take respiratory rate prior to doing any testing. And obviously, having a pulse oximeter is also key for these kinds of patients. So then you can do a simple two minute walk test, for example, which has been designed for patients with cardiopulmonary conditions. Or you could even do a two minute step test if they were a little bit better physically fit. Or on the other hand, you could do a one minute sit to stand test, because that was specifically designed for patients with pulmonary problems. So I think it's going to be really key to select the right test at the right time for the right patient. And you can have an array of simple functional tests that they can do. So that gets basically at the aerobic capacity and pulmonary capacity.

What I would also think of is a couple of quick measures of strength in some way or another. I love grips during the grip strength test because it gives you a very good indication of certainly their whole upper extremity strength. But it also gives you a very good prediction of mortality, morbidity and all sorts of other things, which makes it a really valuable test. So I would do that for the upper extremities and for those factors. I would also think about doing the 30 second sit to stand because that gives me a very good indication of the general strength of the lower extremities.

I might look at, you know, certainly, the two question depression test and two question anxiety test because we know these patients have been an incredibly stressful, fearful environments, not knowing whether they're going to survive or not. And therefore it gives us a very easy test to determine if the patient is depressed and if they are anxious. I probably would look at, depending, certainly not my first visit, but as time goes on, I'd look at a balance test like a one legged stance test just to see what their balance looks like. And in terms of their mobility and balance, I'd probably use a modified Foursquare step, which, as physical therapists would know, was originally designed to be done with canes, but the modified one just uses tape on the floor. And that's, again, a nice, easy test to see if the patient can move in various directions, and how quickly they can move in those directions. So those are the kinds of things I would think of in terms of an outpatient environment.

If I'm getting somebody who's coming in extremely weakened, or I've got them in, again, more of a rehab facility as opposed to outpatient department, I would probably think about maybe something as simple as the Function in ICU Test where you just do four minimal tests, or I might even think about the DeMorton Mobility Test which has again, very nice progressive activities where we get a good indication of their functional mobility and also their activities of daily living.

[MEER] That was so helpful, there were so many things in there that were just, definitely will be a refresher, I think, for many physical therapists who are,who may have been a while since they were in PT school and did some of those, or learned about those tests. But I think that's, it's gonna be really helpful and, and on the site, we'll make sure to include some of those resources so people have them immediately accessible.

You brought up a really interesting point about physical therapists also potentially screening for depression, anxiety, some of the other effects of serious illnesses. And along with your many other achievements, you're also a geriatric clinical specialist in physical therapy. And we know that COVID-19 takes a particular toll on older adults, not just from the virus itself, but the toll of social isolation, the new challenges that are faced by caregivers, they are very real fears of going out or staying active in the community right now,  or running errands. And physical therapists, many of us have pivoted to using telehealth as an option to continue to help reach reach our patients as best we can. As this year goes on, as the pandemic hopefully subsides, do you have any concerns about the long term impacts on older adults in terms of the way that they may choose to live their lives, to stay active or to engage with their health care providers? You know, physical therapy is a is a physical discipline, right? We're meant to be a hands-on working with our patients. And it seems like the landscape may have changed a bit and I am curious to hear your thoughts on how that might impact older adults specifically.

[MOFFAT] I think, you know, physical therapists have to get out of that mode of thinking about we're treating only musculoskeletal problems with some mobilization and exercises. And as you know, I come from the geriatric exercise background. So for me, the key for aging adults is you have got to get them up and moving and exercising and taxing them to the maximum extent to which they can be taxed, because if you don't, you're not getting the maximum out of them. And I think having treated individuals from you know, 50, all the way to 103, and everything in between, I know how much we can push older adults.

And it's really going to be key for these individuals coming out of this kind of environment and this kind of trauma to their systems to get in the hands of physical therapists who really can help push them, right. What I don't want them to do is just go to somebody in the area who's not a physical therapist, who says I can give you some exercises because there are too many potential complications that have occurred with these individuals, that it's going to be key that they really seek out. And if their physician doesn't recommend it, they must demand that they see a physical therapist to get them again back on the road to good health.

[MEER] I love what you said there about about making sure that physical therapists are at the forefront of this in terms of our expertise in evaluating and assessing these patients, and I've come across a lot of resources for how physical therapist should work with patients to make sure that they are keeping folks safe in the clinic when people are coming in or how to treat very actively ill patients in the hospitals based on what we know right now. Do you know, just based on the access that you have worldwide, are there any guidelines that have been developed or are being developed for the standards of care for how to treat folks when they're recovering? Is this something in process?

[MOFFAT] It's coming out and in process. There's already been one article that was published, called Physiotherapy Management for COVID-19 in the Acute Hospital Setting, Clinical Practice Recommendations, and that's just been published. Again, this is a group out of Australia. So there are studies that are out there, physical therapists just have to seek them out. But they're definitely there. That article happened to be in the Journal of Physiotherapy. So I would guide therapists again to take a quick look at those, but that's in the acute hospital setting and not for the outpatient setting. But I think you know, once they get out of the acute setting, and they survived, you've got again, the trauma of what the disease is done and you've got the complications of bedrest. So for me, it's just getting them out there and getting them moving and strengthening and mobility as quickly as we possibly can. We're using all of our capabilities in terms of knowledge of all of the pathophysiological principles that are involved in the management of these patients.

[MEER] Hopefully, this will inspire other physical therapists out there to, to really, to really work hard to do the best that we can by our patients, obviously, and make sure that as these folks come in, we are screening them appropriately and effectively. Dr. Moffat, thank you so much. Do you have anything else to add that to the conversation before I let you get back to, to all the other things —

[MOFFAT] I just, you know, I think it's opening up a unique opportunity for physical therapists to think about the multiplicity of systems that make up the human body, particularly the cardiovascular, pulmonary, and also again, the neurological as well as the whole mental cognitive areas as well.

[MEER] Thank you, thank you again so much. I really, really appreciate you taking the time to speak with me today.

[MOFFAT] My pleasure.

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