490: Dr. Andrew Ball: Rehab After Covid

On this episode of the Healthy, Wealthy and Smart Podcast, Jenna Kantor guests hosts and interviews Andrew Ball on rehab after COVID-19.  Dr. Andrew Ball is a board certified orthopaedic physical therapist with nearly 20 years experience in physical therapy. Drew has earned numerous advanced degrees including an MBA/PhD in Healthcare Management, and post-professional DPT from MGH Institute of Health Professions. He has completed a post-graduate fellowship in Leadership Education in Neurodevelopmental Disabilities (LEND) at University of Rochester, and a post-doctoral clinical residency in Orthopaedic physical therapy at Carolinas Rehabilitation in Charlotte, North Carolina. Clinically, Drew has mastered a wide-range of manipulative therapy techniques and approaches via continuing education and residency experiences (ultimately creating and co-creating several new techniques).

In this episode, we discuss:

-The pathophysiology of COVID-19

-Physical therapy treatment considerations in acute and outpatient settings

-Post Traumatic Stress Disorder among patients and family members

-Functional tests appropriate for patients following COVID-19 infection

-And so much more!

 

Resources:

Email: drdrewPT@gmail.com

Andrew Ball Instagram

APTA Cardiovascular & Pulmonary Section COVID-19 Resources

United Sauces Website 

 

A big thank you to Net Health for sponsoring this episode!  Learn more about The ReDoc® Patient Portal here. 

                                                                    

For more information on Andrew:

Dr. Andrew Ball is a board certified orthopaedic physical therapist with nearly 20 years experience in physical therapy. Drew has earned numerous advanced degrees including an MBA/PhD in Healthcare Management, and post-professional DPT from MGH Institute of Health Professions. He has completed a post-graduate fellowship in Leadership Education in Neurodevelopmental Disabilities (LEND) at University of Rochester, and a post-doctoral clinical residency in Orthopaedic physical therapy at Carolinas Rehabilitation in Charlotte, North Carolina. Clinically, Drew has mastered a wide-range of manipulative therapy techniques and approaches via continuing education and residency experiences (ultimately creating and co-creating several new techniques). He is certified by the National Academy of Sports Medicine (NASM) as a sports performance enhancement specialist (PES) and was personally trained and certified (CMTPT) by Janet Travell’s physical therapist protégé (Dr. Jan Dommerholt of Myopain Seminars) in myofascial trigger point dry needling. Dr. Ball serves on the Specialist Academy of Content Experts (SACE) writing clinical questions for OCS exam, as well as research and evidence-based-practice questions for all of the physical therapist board certification exams.

Dr. Ball currently serves on the clinical and research faculty at the Carolinas Rehabilitation Orthopaedic physical therapy residency teaching research methods and evidence-informed clinical decision making, but also contributes to the clinical track mentoring residents in manipulative therapy and trigger point dry needling. His publication record is diverse, spanning subjects ranging from conducting meta-analysis, to models of physical therapist graduate education, to political empowerment of patients with physical and intellectual disability. Dr. Ball’s most recent publications are related to thrust manipulation and can be obtained open-access from the International Journal of Physiotherapy and Rehabilitation.

Drew is married to his wonderful wife Erin Ball, PT, DPT, COMT, CMTPT. Erin is Maitland certified in orthopaedic manual therapy (COMT), certified in myofascial trigger point dry needling (CMTPT), and has extensive training in pelvic pain, urinary incontinence, and lymphedema management. They live with their two dogs one of which is a tripod who was adopted after loosing his hind-leg in a motor-vehicle accident.

 

For more information on Jenna:

Jenna Kantor (co-founder) is a bubbly and energetic girl who was born and raised in Petaluma, California. Growing up, she trained and performed ballet throughout the United States. After earning a BA in Dance and Drama at the University of California, Irvine, she worked professionally in musical theatre for 15+ years with tours, regional theatres, & overseas (www.jennakantor.com) until she found herself ready to move onto a new chapter in her life – a career in Physical Therapy. Jenna is currently in her 3rd year at Columbia University’s Physical Therapy Program. She is also a co-founder of the podcast, “Physiotherapy Performance Perspectives,” has an evidence-based monthly youtube series titled “Injury Prevention for Dancers,” is a NY SSIG Co-Founder, NYPTA Student Conclave 2017 Development Team, works with the NYPTA Greater New York Legislative Task Force and is the NYPTA Public Policy Committee Student Liaison. Jenna aspires to be a physical therapist for amateur and professional performers to help ensure long, healthy careers. To learn more, please check out her website: www.jennafkantor.wixsite.com/jkpt

 

Read the full transcript below:

Jenna Kantor (00:02):

Hello. Hello. Hello. This is Jenna Kantor with healthy, wealthy and smart. I'm super excited because I have Dr. Andrew Ball here who is going to be interviewed on COVID-19. Has anyone heard of it? Anyone? Bueller, Bueller and return to performance post infection. This is such an important conversation. I'm really excited and grateful to have you on Dr. Ball. Thank you.

Andrew Ball (01:26):

Well, first of all, please call me Drew. And second of all, let me thank you and your listeners for having me on.

Jenna Kantor (01:34):

Wonderful. It's really a joy. Would you mind telling people a little bit more about yourself so they can better get acquainted with Mr. Drew?

Andrew Ball (01:46):

I have been doing physical therapy for, I have a 20 year history in physical therapy. I've taught for a good majority of that time. I started out in pediatrics doing what I was told was the first fellowship in pediatric physical therapy and neurodevelopment at the university of Rochester, which has since kind of turned into a PTA accredited residency program at the strong center for developmental disabilities and then evolved into doing orthopedics. I hold an MBA, PhD in health care management. I went and did a post-professional DPT, but I got to sing. None of that matters really the salient point. And I think I'm using that word correctly. But don't go with it. Go with the pertinent point is that I could be any one of your listeners who treats in outpatient orthopedics who treats in sports.

Andrew Ball (02:48):

My passion is working with musical athletes. I started working with guitarists. I played piano at Peabody when I was a little kid, put that down and Mmm. And ultimately I got back into music by playing guitar, by being forced to play guitar because I was working with guitarists. And at some point it's like working with a football player and never having played football or treating dancers and never having dance. There's a point where there's a level of respect from your patients. You just don't have it unless you actually have, okay, I've done the work. You can't really speak the language. So I recognized that there were two ways, one of two ways to do that. One was to begin building guitars. So I started doing that. And then ultimately one of the guys that I built a guitar for who plays guitar for Carl Palmer formerly of Emerson Lake and Palmer in Asia.

Andrew Ball (03:58):

Basically he told me like, this guitar is great, but you really have to learn how to play or, yeah, I mean you really are going to have to learn the language of the little things like the posture and the whole, you can talk about holding the guitar, but you know, if you're a grunge player and you're playing bass, you've got to play that guitar and you gotta play that bass guitar and your name and it doesn't matter. Cause it doesn't look cool to have it in the right, you know, proper position. And the muscle memory that these guys had been in gals have been doing, you know, since they were you know, 12 years old you know, you're not going to change that. It's like changing someone's golf swing or if you're going to change it, they have to understand that it is going to be for a greater good.

Andrew Ball (04:45):

Like being able to play a 60 date tour versus having shoulder pain after 30. So, I kind of weaved and wobbled through trigger point dry needling. And I also teach for my pain seminars, but that got me into working with the Jamaican Olympic track and field team. It got me into working with the Charlotte symphony and I'm one of the physical therapists for them. But ultimately I am trust like any one of your performance PTs who is interested in that population and at the same time truly truly wants to help individuals that have a hard time finding care. And so that, is that correct?

Jenna Kantor (05:37):

Yeah, I think that's great. I mean you could go on for a very long time and I really want to get to the point because this man clearly he is a person to learn from. He has so much information to share and I'm really happy about this topic that we're diving into with COVID-19. Let's go straight into the point COVID-19. What are the effects that it has on the body that we need to start paying attention to?

Andrew Ball (05:57):

Like the first things that we have to just acknowledge cause this is going to be something new to us to consider. Right. So there's a lot of things that we need to consider. The physical I'll talk about first. And the psychological, which is a piece that we don't, that certainly performance, that's a huge issue, but that's certainly not something that most PTs outside of the performance training group really, really focuses on. So I'll start out with a friend of mine who was one of the first a thousand people to be diagnosed with COVID. She was in Washington state. She was one of the first 250. She's super, super bright. She holds a PhD in aerospace engineering or aerospace engineering design.

Andrew Ball (06:57):

She's a little bit younger than I am. How old am I? Not quite 48 years of age. And she was, is extremely fit very outdoorsy plays an instrument. So I just want to kind of walk through what she experienced. And this could be again, any one of your listeners on days zero, we'll call it before she was diagnosed. She was skiing I believe snowboarding, but skiing and had some aches and a dry cough and fatigue and experienced something that she had never experienced before that she described as chest awareness. Now your patients and folks that you work with are very acutely aware of breath.

Andrew Ball (08:06):

Right? So I kind of asked her, was that what you meant? She's like, no. I felt like I had to consciously think about every inhalation and exhalation that I chose. And that was before, before a diagnosis, but that was faint. She described it as on day one, which is the day that the fever tends to rise. Not everybody has a fever. So there's variability here that she spiked a fever of 102. She had difficulty breathing day two, that worsen. She had a dry cough and we should get into the idea of a dry cough versus a wet a cough a little bit later when we talk about the physiology of this and how it differs from a pneumonia. And had some GI dysfunction as well. And although we kind of talk about the upper respiratory issues, we also need to understand that the virus enters through the injury.

Andrew Ball (09:16):

The angiotensin converting enzyme to receptors. And, there's obviously the majority of those are or in the lungs, but there are some in the GI tract as well. They're actually all over the body, but and that's why some of the lesser talked about symptoms include things like GI disturbance and urinary issues. And in her case loose bowels by day three, that's when she had a virtual visit. And luckily because there were so few folks being diagnosed at that time, she was able to get a clinical diagnosis by that evening coded by Dave. Or that's when she went to the emergency department because she felt like she thought she had a pneumothorax. She felt like she was unable to fill her left lung with air. And they did a chest X Ray.

Andrew Ball (10:19):

They did the nasal swab. That was day four. She described it as touching her brain. I mean, it's a significant swap. /you have to go all the way up to the back of the throat in order to get right. Which is why many folks who feel like they have a mild case when they hear that they choose not to engage the healthcare system. And I really think that's a bad, bad, bad, bad decision. Because yes, 80% of folks are gonna have a mild to moderate case, but those 20% that you carry it to can have a severe reaction to the virus. That can be, it can be fatal. Five through nine, her fever began to break. Roughly day seven, she had a reflexive excuse me cough.

Andrew Ball (11:21):

She was unable to sleep. She felt like your ears were completely clog. She was coughing up blood and coughing so much that she had conjunctive like conjunctivitis, like that redness in the eyes. Day nine was what she described as noteworthy and describe that as intense exhaustion to the point where she had trouble lifting a spoon. She had trouble zipping up a jacket. And it wasn't until day 11 that she felt like having any kind of food or any kind of coffee. Now here's the critical point is performers or super, super attuned to the idea of I felt bad. The show must go on. I've got it. Push it there. And roughly day 11 through day 14, that's when the viral load is decreasing, but the inflammation is increasing. That's when people go on to ventilators. That's when people kick into this cytokine storm that we've heard of.

Andrew Ball (12:27):

And it's critical to understand that as a healthcare provider and certainly as a patient or performer, cause there have been a number of cases where people had mild cases and they push themselves during this phase a little bit too soon and died having had very, very mild symptoms and then took a turn as a day 14, she still had some difficulty concentrating. She was still exhausted. She found it exhausting to speak and still had a morning sore throat and that's considered a mild.

 

Jenna Kantor:

Okay. Wow. So I think that's, that's important to understand where these people have come from. You know, we don't, well we can get into the idea of ventilation and whatnot before we do it probably makes a little bit more sense to get into this kind of case and how we would treat them coming out of this when they can have contact and we can help them.

Andrew Ball (13:36):

Yeah, absolutely. Yeah. So kind of jumping forward into well let's take a step back before we do that. If you don't mind just into the pathophysiology a little bit, where would you like to jump back and forth? Let's if we do the pathophysiology, just because I don't want this podcast to be too long. Let's make it very brief, very, very brief so that way we can move forward. So I think it's important to understand that COVID-19 is not influenza, it's not cystic fibrosis, it's not pneumonia. And those are the diseases that when you took cardiopulmonary physical therapy, like that was the primary focus was these diseases where the airways would fill with mucus. That is not at all what happens in COVID-19. So a percentage of folks get acute respiratory distress syndrome and it's a dry cough.

Andrew Ball (14:32):

And the reason that it's a dry cough is that the airways don't fill with mucus. What's happening is that the capillaries begin to leak fluid into the lung tissue itself. So think that like lymphedema of the lung, which sounds horrible, right? So the airways are getting, a couple of things are happening, the airways are getting squashed, but still get kind of in and out, but the elasticity of the lungs is going to decrease considerably. And why she felt like she had pneumothorax. Exactly. So, the lungs start to stiffen. Much more fluid within the lungs in the lungs lining. So if you think of the lining like a balloon and having that kind of the alveoli, having that kind of consistency, normally it's as though you took Vaseline and you just slathered the balloon with Vaseline and then expect for the gas to exchange at the same rate in between that membrane and it just does a brand harder thinking of this and that.

Andrew Ball (16:10):

So the problem is not mucus. The problem is ventilation and perfusion. So part of the reason why I got very interested in this is there is a role obviously for quarantine workouts. And by that I don't mean, you know, our brave soldiers within our profession that are in acute care in the ICU and are turning patients so they don't get bed sores and turning them into prone for optimal ventilation profusion. That's not what I'm talking about. I'm talking about the therapist that the only thing that they're posting is information on what healthy people can do when they're stuck at home. And there's a place for that short, but I really feel like there is a role and a responsibility that our profession has to educate the public and to educate each other about COVID-19 and little things. So I started out just asking questions about what can we as physical therapists do?

Andrew Ball (17:20):

Right. You know, I went back to my cardiopulmonary books, you know, what is the role of putting people into a head down, a position that postural drainage. So they can get the mucus out. Well, newsflash, they don't have mucus, right? So that's not going to help. And it's not the best position for Benadryl for ventilation profusion. So that's important. And the other thing I started asking was, well, what about chest PT? You know, I was awesome at chest PT. I haven't done it since graduation, but I remember that as well. The problem with that, again, no mucus, the clear, the only thing that you are going to do if you are trying to help a performer with a mild case who is getting over COVID-19 is you will weaponize an aerosol the virus. So, you know, there were several folks that were suggesting that based on a poor understanding of the physiology and now we really have to retool and get the information out that no, the best position for somebody who has an active case of COVID-19 is prone because that optimizes ventilation profusion because of fluid dynamics and the anatomy of where the alveoli are.

Andrew Ball (18:37):

So I think that's important to understand because in performance, you know, we fast forwarding, we like to think about things like posture, right? Posture may, it can't hurt, but it's not going to make the huge effect that we think of. With some of the other respiratory structural kinds of problems. Can you see, Oh, taping can be somewhat helpful for folks who have breathing dysfunction and until folks get very, very, very far in their recovery process, that's probably not going to be helpful. When I talk about prone, these folks have been placed in a prone position for the minimum protocol I've seen is 12 hours, but usually it's somewhere between 16 and 18 hours a day and a 24 hour period to optimize ventilation perfusion.

Jenna Kantor (19:35):

Right. That's exactly right. Well, the other issue getting into the psychology of all this, Isolation, psychosis, delirium, and these are people who are in pain and I have a hard time taking a breath. Right? They can't have family members can't have family members in there. Right. So what do you think the impact of that is going to be when you see the patients six to eight weeks after the resolution of symptoms in outpatient or as a performance based therapist?

 

Andrew Ball:

Yeah, it's going to be probable in more than 50% of cases, 54% of cases. It's going to have a huge mental health impact that you can see at least 12 months later as PTSD. Now, I don't know about you and the musicians or performers that you've worked with myself included.

Andrew Ball (20:42):

I don't think that we're the least bunch and you layer, post traumatic stress a top that and what you end up with if you don't understand that walking into the room with the patient when you do the evaluation or when you treat them is a whole group of individuals, half of these folks who are going to have behavioral reactions to everything from the frustrations of making their appointments down to frustrations with the treatment process. It's just going to blow up seemingly out of nowhere. And I'm here to tell you it's not out of nowhere.

Jenna Kantor (21:25):

I get it. When you're talking about the psychological component, Oh, that's such an untapped situation. This is also new to us.

Jenna Kantor (21:39):

I don't know. I mean I guess it would just, I mean, off the top of my head would just how I am with my people when I'm with them. It's just really checking in, just checking in, asking. I would just keep asking and being like, are you okay? Let me know if this is starting to freak you out in any way. I think that that's gonna be the big thing. Like I need you to feel comfortable. I need you to feel safe and has to just be that level of, I mean, which we always have any way, but a new level of thought process, you know, sensitivity where something like going, even prone could make them go, you know, and they don't even know. They don't realize they're doing it. Their whole body could just even just naturally tense up and it could just become harder to breath just because they develop a new habit to feel like that's what it's going to feel like when they're on their stomach. We don't know.

Andrew Ball (22:28):

Fortunately or unfortunately, there's a ton of research. Oh, I'm working with patients with post traumatic stress as a function of you know, I don't want to get political here, but as a function of endless military action that are had over the course of the past years. So there's a fair amount of information on that, but awareness is going to be critical in working with these patients. Going back to infection though the question that I get asked probably more often than anything else is when is it appropriate to begin working with these folks without personal protective gear? And the answer to that is, there's some guidelines from the European rehabilitation society, but we really don't know. What we know is that patients can go stealth and can be contagious long after their symptoms disappear.

Andrew Ball (23:37):

And there's at least one case study a well written case study showing that the symptoms that the patient can shed the virus for 37 days after they're no longer symptomatic. And the problem with that is that here in the United States testing is scarce, right? To diagnose it, to say nothing of when are you clear completely of the virus. I'm not aware of widespread secondary testing. And then some of the guidelines from like the world health organization suggest that someone needs to be tested. I think it was in China. Needs to be tested twice and have a negative result twice before they're clear. And if we're not doing that, then we really have to wait six to eight weeks.

Andrew Ball (24:44):

And that's why, because you're going to be long, long past what we know to be the longest reported case. Now whether or not your patient is that, you know, new one that can where they stick around shedding the virus for 42 days or 48 days, you know, we don't know. And one of the scarier things from a public health perspective for me is the recognition that this is an RNA virus, which means that it's going to be harder to create a vaccine because like the common cold, like the rhino virus it slips, it mutates quickly. No, fortunately that has not happened.

Andrew Ball (25:49):

But there is every reason to be worried. And I don't want to freak people out, but there's every reason to be concerned that if we don't kill this thing this year, that it's going to come back every year in a slightly different form, perhaps more contagious, perhaps more stealth, perhaps more deadly. Perhaps it will shed the virus for a longer period of time before we were able to begin working with patients, which kind of gets to that economic effect. I understand that people are hurting. I understand that folks have private practices and cash based practices that have limited cashflow and they're hurting. I totally get that. Yeah. I mean, you know, and folks go, Oh, you don't understand. You work in a situation where you don't own your own practice.

Andrew Ball (27:01):

Well, that's true. You know, I have a significant impact income from teaching. So, you know, I get it. I understand that the dollars are tight, but if you told me that if we shut down for an additional two weeks and we can kill this thing completely, I would do that even if that meant a significant decrease in my salary. And at some point, I think that, and I'm not saying that everyone is a clinical doctor in our profession, I've gotten some feedback for that. But as a clinical doctoring profession, I do think that we have a solemn responsibility to the public in terms of educating on COVID-19 versus kind of filling the Instagram space with Mmm. Lots of home workouts, which are important. People need to keep fit and certainly keep their minds going while they're in quarantine.

Andrew Ball (28:10):

The problem is that there's so many outpatient private practice, cash based PTs that have a such a voice on Instagram that some of this information about just the mechanics of the disease, the physiology of the disease, how long you need to wait in order to protect yourself and your patient from either reinfection or infecting others just isn't pushing through. So, once again, thank you for allowing me to come on this podcast because I do think that those of us who have a voice in that space have an obligation to get some of this information.

Jenna Kantor (28:57):

Wow. Yeah. Yeah. It really, it is very valuable. I want to actually dive in, even though we've been going for a while, I think it is important to dive into now somebody who had the ventilator. Yeah. I think that, that we can't overlook that. There will be some people who've been that unfortunate. So could you talk about what that means with somebody who has been fortunate to recover from such a horrific.

Andrew Ball (29:28):

Sure. So, as I said, about 80% of patients are going to have a mild to moderate and they won't be hospitalized. They may, because of the stress and strain on their lungs, they may develop pneumonia, so they may actually end up, you know, having secondary sputum. But those are folks who, even with the pneumonia are going to have something that we consider a fairly mild case. 20% are going to be severe to critical. And the severe group are the ones who are going to have dyspnea. They're the ones who are going to have rapid breathing that's defined as more than 30 per minute. Their oxygen saturation is going to drop to 93%, and they'll have on a cat scan, you'll be able to see lung infiltrate. That looks like kind of a grounded glass appearance of about 50%.

Andrew Ball (30:30):

So, and then you've got 14% that are severe that fit that classification and about 6% that are critical. And that's respiratory failure, septic shock, multiorgan failure. And within that group, okay 20%, about 25%, we'll end up in the intensive care unit most of which or many of which will end up on a ventilator. And if you end up in the ICU on a ventilator, your chance of survival is about 50%. So what tends to happen with that ventilated population is on roughly about day 14 we talked about how the viral load increases and then decreases while the inflammation increases. Well as the inflammation in the lung increases okay. A percentage of those folks, as I said, will end up roughly around day 15 needing to be ventilated for about four to five days. And half of them will come off and half of them will not. So the people who come off their recovery. So their recovery we don't, again, there haven't been a ton of folks, so we don't know a ton. What we do know is that in severe cases, there's going to be ICU acquired muscle weakness. They're going to have a severe loss of lung function, a severe loss of muscle mass.

Andrew Ball (32:16):

Yeah, we're getting younger too, but just as things been saying percentages. Yeah. neuropathy, myopathy. The good news is, is that we can begin to protect recovery. And the greatest, what we know is that the greatest amount in physical function will be seen. If the patient falls into acute respiratory failure, we'll see that within roughly the first two months of discharged. So that gives us some kind of a gauge. In addition the degree of disability at about a week after discharge determines the one year mortality and recovery trajectory of that individual. So we have some guidelines as far as that's concerned from acute respiratory distress syndrome, right? So that's not necessarily coded, but we believe that we can extrapolate in general what we haven't talked about is the impact on them.

Andrew Ball (33:30):

And the fact that about 30% of family members of individuals with acute respiratory syndrome end up with PTSD. So now you have this group, we're 50% of folks who have been in the ICU have PTSD and 30% those folks have family members who have PTSD. How do you think that's going to go down or like, a lot of them can't go into the hospital, but they can do a FaceTime video. So what they get to see in that FaceTime video with their loved ones in the hospital, I'm talking about after they're discharged. I'm talking about later. Yeah. No, but I'm just saying the family members with the person, I'm like their interaction. That's what I'm referring to, their reaction with it. If you're prone for 16 to 18 hours a day, right?

Jenna Kantor (34:07):

Yeah. So what do you do with these folks when you finally see them? Right. So you're going to have chocolate. Chocolate makes people happy. Right? It's funny, it's funny you say that. I'm doing a webinar with some some other instructors that I teach with and we're kind of talking about the format. And I'm a huge fan of the old school. I love the daily show, but I'm a huge fan of the old daily show with Craig Kilborne. He used to do the thing where he would like ask opinion questions. I'll ask you Reese's pieces or M&Ms no, I'm sorry. The correct answer is eminence. No, I'm sorry you were wrong. No, I would agree. But that's what he would say.

Jenna Kantor (35:13):

He would end with those kinds of questions. Kind of like his version of the James Lipton kind of five questions. What do you hope that God says when you die anyway, we're getting off track. So what I'd like to kind of go through is you're going to have folks that have worked with you in the past. They are post infection. Ah, they’re your dancers, they're your musicians in the pit. They're your directors. They're your loved ones that are going to refuse to see anyone. But yeah.

 

Andrew Ball:

Right. And of those folks, you're going to need to know what to, you know, what to do. I would say if you hear nothing else from me, remember your vitals and there's, it has to be a Renaissance now of taking heart rate, taking respiratory rate, taking oxygen saturation, taking blood pressure with every patient.

Andrew Ball (36:12):

The functional tests that we're probably gonna have to start using are things like ambulatory distance, which is going to be severely decreased. We'll be lucky if some of these folks are able to walk 300 feet. Some of them, right, if they're severely impaired. You know, that's not far enough to get from your car to a doctor's office. You normally need about 500 feet for that to say nothing of getting back to your daily life and doing your own grocery shopping with which you need at a super target or R or Walmart, you need a good half mile, you need a good 2,500, 2,500 feet. But things like the five times sit to stand test or test that we're going to need to brush up on the six minute walk test. Fortunately we can remote monitor some of those things.

Andrew Ball (37:05):

Tele-Health isn't just you know, getting on a zoom call with somebody tele health, we need to think of that in an expanded way, right? There's apps that will allow for you to do a six minute walk test or your patient to do a six minute walk test and then send you those results remotely from there, from their app. Some folks aren't going to be able to walk for six minutes, right? So at that point we're going to have to back up into feet per second or four meters per second. And we have some metrics for that. You know, we know that somebody who's under 70 at a normal walking pace should be able to walk a good 2,500 feet at a 4.0 feet per second. So, you know, somebody comes in completely deconditioned and they're walking 1.5 feet per second for 500 feet. We've got some work to do.

Jenna Kantor (38:36):

Yeah, totally. Yeah. You know, don't forget about deep breathing, deep dive. And I don't just mean you know the breath, but I mean the breadth, I mean the deep diaphragmatic breathing, bringing it all the way down into your belly, your performers should be well for those dancers who sing, that's huge. That's so huge to reconnect with it, even though that may seem so basic with them before, but have they caught the disease. And, for sure to make sure that starts to get all connected and back in check and not a stressful

Andrew Ball (38:43):

Right. You know, and then I look into things that, Mmm, that as I've spoken with some cardiopulmonary specialist, you know, all of this comes from the European rehab society. I also want to plug the American physical therapy association. I shouldn't have done this at the very top of the of the discussion. But the pacer project, the post acute  COVID-19 exercise and rehabilitation program, it is completely free, but it's time intensive. Mmm. You know, they've tried to break things down into 45 minutes or hour and a half lectures, but there's like eight or 10 of them. You don't have to watch all of them. It's free. If you want to get the certification and the CEO's is fine, go through the APTA learning center, but they've put everything up on YouTube and all you have to do is search APTA cardiovascular section and you'll get the the literature. I think a lot of orthopedic sports performance based PTs they're really tech savvy and they kind of want to get the information through podcasts or a like a one hour presentation. So that's, well, essentially what I'm trying to do is to translate.

Jenna Kantor (40:08):

That's what's so great. I mean I'm going to be sharing this in groups as well to keep spreading the information, which is absolutely wonderful. This is good.

Andrew Ball (40:21):

Well, I do add in a couple of things that I've kind of brought to there. Okay. So some of their attention and because they're kind of case study oriented, they're like, well, we're really not teaching that. But particularly for it can't hurt. And particularly for performers humming and I don't mean like humming a song. I mean a long, deep droning

Andrew Ball (40:52):

There's evidence to suggest that it temporarily increases carbon dioxide and it temporarily increases nitric oxide. And in so doing leads to temporary base or dilation, so it can't hurt. I don't know how long it actually lasts. Certainly the deep breathing and increasing walking distance and walking speed is more important. But if you're bored and have nothing else to do while you're in quarantine humming is probably not thinkers would appreciate that.

Jenna Kantor (41:28):

They'd be like, yeah, for sure. That will be a vocal way for them to get that all connected. Also nasal, yeah, there's a lot of stuff with training and staying vocally fit, if you will. So that would actually speak to there values.

Andrew Ball (41:44):

Yeah. Yeah. I could go into a lot more here. I just want to make sure that that folks have a good kind basic understanding here. You know, we've heard, you know, wash your hands, wash your hands, wash your hands. So I'll make a plug for wash your hands, wash your hands, wash your hands. And even in some other countries where the health care workers understood the severity of COVID-19 the healthcare workers seem to be a risk to themselves because they didn't properly and thoroughly and frequently wash their hands. I would say whatever you think you're doing, it's probably not enough. Okay. The other thing that I would say about the hand sanitizers that we tend to use the world health organization and FDA suggest 75 to 80% alcohol.

Andrew Ball (42:50):

And that is not what most clinics have. Most have like the foam sanitizer or the like the Purell, which is 60%. Okay. You know, plugging performers amazing, okay. Guitarists, my performance Buddha and spirit animal is Ron Bumblefoot fall who is in the band spun. Do you know who that is? No, it's not the name. He's in sons of Apollo. He was the lead vocalist for Asia this last tour. And those of you who love guns and roses he was the guitarist the main guitarist on the last guns and roses album. Chinese democracy is ridiculous as a player and he's amazing as a teacher as well in any of that. He also has a line of hot sauce and one of the, and I just love when performers do this and kind of take responsibility for the position that we're in, but a Unitedsauces.com which is the distributor that he works with has retooled one of their lines to put out hand sanitizer that is 75 to 80% alcohol.

Andrew Ball (44:20):

So that will in fact kill the Corona virus. So, Mmm. Great. Local company here in Charlotte. Highly, highly recommend and plugged them. Hey, you want to support a performer you know, during these times. And the last thing that I will leave folks with is as you are working with patients post infection, ask yourself, do you need to put your hands on this patient? Can this be done remotely? And I'm really more talking you know, it really more talking to the folks who do outpatient work, who have their own side hustle who do work in a healthcare system who are going to be pulled inpatient, right? You know, either somewhere like New York city where you are. And folks have to be kind of pulled in, you know, right down to the rural hospital you know, in the middle of nowhere.

Andrew Ball (45:32):

And there's two physical therapists, one inpatient, one outpatient, and they need help working because now they have more folks that are getting ill. You know, really ask the question, both inpatient in your cash practice, in your private practice for the sake of killing this thing. And for the sake of decreasing whether or not you're a force vector, do you need to provide that treatment? And is there someone else who can be your hands? Can you delegate that to a nurse? Can you delegate that to a family member? I really think that we're going to a friend of mine who runs another podcast Adam Meakins, has been talking about physical therapy in terms of AC DC during COVID and after COVID. And I really think that all areas of practice are going to change as a result ranging from the little things that I just talked about, you know, having to do vital signs with everybody right down to really asking the question, can I go from an interdisciplinary model of care to a transdisciplinary model of care?

Andrew Ball (46:58):

Can I let go of that professional boundary and ego. And I know that a lot of my contemporaries are not going to be comfortable with that. I think we have to be secure in the knowledge that we have more than the hands that we place on people. It's all important, but I do think that there's going to be a paradigm shift.

Jenna Kantor (47:30):

I love it. Thank you. So, for coming on, Drew, this was an absolute joy. Where can people find you and reach out to you either on social media or email?

Andrew Ball (47:39):

Well they can reach out to me. I'm on Instagram @drdrewPT. They can email me at drdrewPT@gmail.com. If I don't respond, I have a ton of spam filters. So don't be shy about reaching out to me through social media. But I really want to make it clear. I'm not the expert here. The true experts, you know, are people like Steve Tepper Ellen Hilda grass Angela a beta Campbell Telia polic you know, these are the folks that we really should be talking to are Eric. And if you really want more information, I'm happy to direct people to it.

Jenna Kantor (48:37):

That is helpful. Yeah, absolutely.

Andrew Ball (48:39):

The Easter projects, the post acute COVID-19 exercise rehabilitation project is really where folks want to go for more in depth information from physiology to post acute through the entire spectrum of post acute care.

Jenna Kantor (49:00):

Absolutely. Thank you. Thank you. Thank you for coming on. You guys give a big shout out to him if you have seen this, just so he can really see how he has impacted so many. Thank you so much for coming on, Drew. Have a great day, everyone.

 

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