key: cord-268040-6i0bmnee authors: Dean, Elizabeth; Jones, Alice; Yu, Homer Peng-Ming; Gosselink, Rik; Skinner, Margot title: Translating COVID-19 Evidence to Maximize Physical Therapists’ Impact and Public Health Response date: 2020-06-26 journal: Phys Ther DOI: 10.1093/ptj/pzaa115 sha: doc_id: 268040 cord_uid: 6i0bmnee Coronavirus disease 2019 (COVID-19) has sounded alarm bells throughout global health systems. Late May, 2020, over 100,000 COVID-19 related deaths were reported in the United State, the highest number of any country. This article describes COVID-19 as the next historical turning point in the physical therapy profession’s growth and development. The profession has had over a 100-year tradition of responding to epidemics including poliomyelitis; two world wars and geographical regions experiencing conflicts and natural disasters; and the epidemic of noncommunicable diseases (NCDs). The evidence-based role of non-invasive interventions (non-pharmacologic/non-surgical) that hallmark physical therapist practice has emerged as being highly relevant today in addressing COVID-19 in two primary ways. First, despite some unique features, COVID-19 presents as acute respiratory distress syndrome (ARDS) in its severe acute stage. ARDS is well familiar to physical therapists in intensive care units. Body positioning and mobilization, prescribed based on comprehensive assessments/examinations, counter the negative sequelae of recumbency and bedrest; augment gas exchange and reduce airway closure, deconditioning and critical illness complications; and maximize long-term functional outcomes. Physical therapists have an indisputable role across the COVID-19 care continuum. Second, over 90% of individuals who contract and die from COVID-19 have co-morbidities, most notably cardiovascular disease, hypertension, chronic lung disease, type 2 diabetes mellitus, and obesity. Physical therapists need to redouble their efforts to address NCDs by assessing patients for risk factors and manifestations and institute evidence-based health education (smoking cessation, whole-food plant-based nutrition, weight control, physical activity/exercise), and/or support patients’ efforts when these are managed by other professionals. Effective health education is a core competency for addressing risk of COVID-19 as well as NCDs. COVID-19 is a wake-up call to the profession, an opportunity to assert its role throughout the COVID-19 care continuum and augment public health initiatives by reducing the impact of the current pandemic. For over 100 years in industrialized countries, physical therapists have specialized in human movement and functioning irrespective of disease and its severity (from the community to the ICU) and chronic disability. It has become the third largest established health profession in the world, excepting dentists and pharmacists who have distinct practice patterns. 10 Physical therapy has been largely hallmarked by its non-invasive approaches, ie, non-pharmacological and non-surgical approaches, and competencies, and has applied this perspective through a history of responding to epidemics including poliomyelitis, two world wars and geographical regions experiencing conflicts, wars and natural disasters, and most recently NCDs. 11 The profession has emerged from a tradition of applying passive interventions to maximize movement and function, to a more holistic comprehensive tradition of exploiting means of maximizing overall health and wellbeing to augment movement and function. 5 Throughout its history, the physical therapist profession has correspondingly responded in terms of maximizing people's health and function by exploiting non-invasive interventions to the Because of this, the ICF has been supported by the World Confederation for Physical Therapy (WCPT) 23 and its member organizations. This was another turning point that advanced patient assessment, evaluation and examination to include broad dimensions beyond limitations of structure and function, to activity and participation, and assessment of contextual factors such as the patient's environment and personal factors including lifestyle behaviors. All the while, the research intensity of the profession has been unprecedented and has grown exponential over the past 40 years in terms of securing competitive grant monies and publishing in high-ranking peer-reviewed journals. About 85% of COVID-19 cases are mild and may even be undetected. 24 Ten percent of those The physical therapy community has responded expediently with the publication of practice guidelines for the acute management of patients with COVID-19. [35] [36] [37] These guidelines and recommendations largely build on the position statement for physical therapy for adults with critical illness published in 2008. 38 However, that patients in the ICU generally do not do well months, often years, after post-ICU discharge has reinforced the notion that the continuum of care including physical therapy needs to extend for months afterwards. [39] [40] [41] With The association of comorbidities, ie, NCDs, with increased susceptibility to COVID-19 and poorer outcomes including survival, has been well documented. 44, 45 Given the prevalence of NCDs in the United States and increasingly around the world, most people have one or more risk factors or manifestations, which makes them vulnerable to COVID-19 infection. This being the era of NCDs, 46 physical therapists have long been urged to exploit lifestyle and behavioral medicine competencies, 47 to reverse NCDs and their risk factors, eg, atherosclerosis, smoking, hypertension, type 2 diabetes mellitus and obesity, often within days or weeks, and atherosclerosis within one year or more. 48, 49 In the United States, 94% of those who have succumbed to COVID-19 have at least one comorbidity, primarily related to lifestyle-related NCDs; in Italy this figure is 99%. 50 Only 1 in 5 Americans engage in 4 or more healthy behaviors, whereas almost half of them participate in fewer than 3 healthy behaviors. 51 Increased participation in numerous healthy behaviors can decrease premature mortality, decrease the burden of chronic diseases, improve life quality, and provide substantial economic benefits. 51 Thus, reducing such susceptibility is critical. Improving lifestyle behaviors has been well documented to prevent, reverse, as well as manage NCDs. A public health practice of targeting a constellation of behaviors as opposed to individual behaviors is needed. 52, 53 Smoking, sedentary behavior, physical inactivity, and obesity are an independent risk factors for metabolic syndrome, 54-56 as well as cardiovascular disease, and all associated with elevated markers of low grade systematic inflammation. Consistent with the recent report of the Lancet EAT Commission, 57 the American College of Lifestyle Medicine advocates a whole-food plant-based nutrition to maximize health, prevent disease particularly NCDs, reverse these conditions, and reduce disability, premature death and socioeconomic burdens associated with them. Such a dietary regimen has been well established to reduce risk of heart disease, cancer, high blood pressure, type 2 diabetes, and obesity, and their relative, metabolic syndrome, 48 conditions unequivocally linked to more severe COVID infections and poorer outcomes including death. In some instances, such as hypertension and elevated blood glucose, these can be reduced within days or weeks. 58 Atherosclerosis can also be reduced or resolved with dietary changes and exercise, however these effects can take many months. 59, 60 Overweight can be addressed with a healthy plantbased nutrient-dense diet and exercise. 61 Variations in host immune responses might be explained in large part by the healthfulness of the host's lifestyle and behavioral factors including nutritional choices. 41 Thus, immune responses to COVID-19 and mechanisms of hyperinflammation-driven pathology warrant elucidation to best define therapeutic strategies for COVID-19, 62 including nonpharmacologic strategies such as healthy nutrition and exercise. A secondary gain of healthy nutrition could be lower incidence of physical impairment, 63 irrespective of body mass. Effective health and lifestyle education are unique physical therapist competencies. 47 As the leading established non-invasive health profession in the world, the profession needs to assume a leadership role with respect to including in their practices and entry-level education curricula, health and risk factor assessment and prescribing health promoting interventions or indications for referral to others. Effective health and lifestyle education, ie, lifestyle knowledge translation, warrants being ever more so at the forefront of every physical therapist-patient interaction. 66 At a broad level, the physical therapy profession needs to ensure that health providers and stakeholders continue to be updated about the profession and practitioners' competencies as the professions continues to evolve and serve global societies. This will ensure that stakeholders such as legislators, ministries of health and higher education, hospital managers, university administrators, and other health professions, continue to support the physical 13 therapy profession in its practicing at its highest evidence-informed level, in the interest of health and participation for all. The unprecedented global crisis of COVID-19 has become an unprecedented opportunity for the physical therapist profession to continue to advance along its evolving historic trajectory, commensurate with societal and global needs. The profession has an opportunity to respond impactfully. We conclude that the COVID-19 pandemic could well augment the profile of the profession of physical therapy within the health professions and within public health, given its potential role in reducing COVID-19 susceptibility, and its management from its most severe expression, ARDS, to maximizing functional return long after hospital or ICU stays. Prevention and outcome of COVID-19 could be substantially impacted with exploitation of non-invasive strategies including health and lifestyle education and exercise, that are subsumed within contemporary physical therapist practice. This is an unparalleled opportunity for the physical therapist profession to step up to the plate, and to further establish itself among the health professions and demonstrate its worth. There is no funding to report. Accessed June 15. 2020. and reduce the burden of non-communicable diseases Postmortem examination of patients with COVID-19 Endothelial cell infection and endotheliitis in COVID-19 Post-discharge cardiac care in the era of coronavirus 2019: How should we prepare? World Health Organization. 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