Chronic Disease Part 4: Type 2 Diabetes – Part 2

Make sure to check out Part 1 of this series HERE!

Let’s Jump Right In

And… moving on! I made some promises in the last post about the diabetic foot, diabetic ketoacidosis, insulin sliding scales and other medications, and using exercise to treat diabetes, so we are going to go through a few posts to cover those topics and get you ready to fully manage folks who have Type 2. This part of the series will focus on diabetic foot management.

As PTs, we frequently look at, touch, and work with people’s feet. Most people have feet and our feet are the base of our body. There is an older book out there called When the Foot Hits the Ground, Everything Changes and it was a standby resource at one of my old clinics. Needless to say, the feet are pretty important. But some populations, the diabetic population, in particular, have a pretty high risk of losing their feet (or parts of them). Amputees are a large part of my caseload and I can say that with certainty across any setting. Home health, skilled nursing, subacute rehab, inpatient rehab, acute care, outpatient… yep, lots of missing parts. Not all of them are due to diabetes, but in the Geriatric population, many are. And those are my people.

So, let’s talk about feet!

Photo by Pixabay on

The Diabetic Foot

Because the feet are at the bottom of the body, they are typically the furthest from the heart (or the pump) and, therefore, receive blood with the assistance of gravity (because gravity helps the blood go downward). As blood vessels get further from the heart, they also tend to get smaller, and if you do some basic math, that means that the blood in your feet will likely be under higher pressure than the blood in your arms, but the difference shouldn’t be too far off in a well-functioning system. You can read more about that here.

Now, those smaller blood vessels have a lot of work to do, supplying all the small muscles, nerves, bones, and other tissues in the feet, and then return all the waste products from those tissues back to the removals systems in our body. Getting blood down to them is not usually an issue, but because blood has to work against gravity to return to the source (the heart), our body has valves in the veins to help keep the blood from flowing back down to the feet after it has left. This process is also assisted by muscles in the legs that squeeze the arteries and veins as they contract and relax. If you’ve ever been told about ankle pumps or have taught someone to do ankle pumps, this was probably the reason behind that activity: help pump blood, waste, and fluid out of the feet and against gravity.

So far, this should all sound pretty basic, which is great! because most of these things to this point aren’t that complicated. However, when you add diabetes to the mix, things start to change and the whole system begins to become far more complicated. Let’s talk about peripheral vascular disease for a minute.

Photo by EVG Kowalievska on

Now, I could talk about vascular disease pretty much all day, but the gist of it is that when blood glucose (or “blood sugar”) levels go unchecked, this causes damage to the endothelium (the most intimate and fragile layer of the blood vessels). This damage results in scar tissue and other things that shouldn’t be there getting deposited within the wall of the blood vessel. This scarring and buildup cause the blood vessel walls to harden and, eventually, the muscles within the walls of the arteries do not work anymore. The artery just becomes a stiff pipe that cannot respond to increased or decreased demand for blood and oxygen from the tissue below (in the foot). The tissues of the foot are then starved for these vital substances and cannot maintain good tissue health. And now we’ve gotten to where we are going… It’s a bit of a long road and it takes some winding turns, but let’s talk about what all that means. We will go by tissue type:


Nerves require a blood supply to function. Nerves are also myelinated (or covered in fat) which helps them carry signals faster than they otherwise could. This fat also requires blood supply. When nerves don’t get the oxygen and nutrients they need, they can’t send signals properly or quickly, which can result in erroneous signals or a lack of signals. In patients with diabetes, we often hear this called neuropathy. And, in people with diabetes, this neuropathy happens distal (or furthest away) to proximal (closest) resulting in a stocking-style presentation of paresthesias or anesthesia.
Of note, in the upper extremities, it can present in a glove-live pattern. I see this more often in people who have Type 1 diabetes, but we are talking about the feet here.

If the nerves aren’t sending signals properly, or at all, the foot can’t feel the sock or shoe it is in. This can result in pressure sores from improperly fitting shoes or broken-down shoes. Wounds can get infected pretty easily when they are on the feet, so sepsis ensues and this is how feet are lost. The foot also can’t feel the ground, and this is a big one because that implies effects all the way up to the brain. Here’s what I mean: If the foot can’t feel the ground, then the brain has to use other mechanisms to ensure it is on the ground, like the vestibular and visual systems. These three normally all work together, but now only two are working properly, so that patient has lost one-third of their balance systems. Now we have an increased risk of falls.

Photo by Thought Catalog on

Just as there are blood vessels to nerves, there are also nerves to blood vessels, so their function is intricately intertwined. There are intimate interactions between the nervous and vascular systems, and malfunctions in one will result in malfunctions in the other. This also contributes to neuropathy and several other neurovascular issues throughout the sympathetic and parasympathetic nervous systems which impair the body’s internal management of insulin and blood glucose. But that’s a complex topic for another time.


If skin cannot get a good supply of blood, it will have to retreat its resources to the deeper layers that protect organs and sacrifice the superficial layers. This results in patients with diabetes having very dry, fragile, and flakey skin, especially on their feet. It is a common part of the diabetic foot assessment to remove a sock and find a snowbank worth of skin flaking off. I know, it sounds gross, but the body just can’t supply all the layers, so they shed off faster. This also means that the hair follicles die and sweat glands are dysfunctional. The skin also breaks down much faster due to the increased fragility. Again, this results in an increase in risk for wounds, infection, and many other impairments.

And let’s remember that this fragile skin doesn’t have a good blood supply, so when it does eventually break down, blister, get punctured, cut, or burned, it will not heal at a normal rate because it cannot get what it needs.

Muscle, Ligament, Tendon

Muscles have a very high demand for oxygen and nutrients when they are at work, so you can imagine that the muscles in the feet have a high demand often, because whenever a person is standing, those lower legs and feet are working. However, the muscle can’t get the blood flow they need, they cannot contract strong enough or long enough to achieve their task. This ischemia can result in muscle pain. Muscles also produce a lot of waste products from their energy use, and a lack of blood flow results in those waste products building up in the localized region of that muscle. These waste products further damage the endothelium and cause an iterative cycle of damage if left unchecked.

Ligaments and tendons are interesting ones because there is a heavy amount of interaction with the neurovasculature in the function and structure of these tissues and the impact of diabetes on them is clear, but not completely understood. Tendons and ligaments house small organs that perceive many sensations we don’t actively think about, but critically need to stay upright, like kinesthesia and proprioception. The loss of these senses means the ligaments and tendons can’t adjust their tension properly with movement. Specifically in the feet, a loss of ligamentous and tendonous support to the structure of the foot can and will cause serious issues We often see this at its end stages and call it Charcot foot. This is a complex presentation of foot deformity that ultimately results in the collapse of the midfoot, resulting in a rocker-bottom-shaped foot. You can imagine that something like this does not fit well in a shoe.

From a PT perspective, this doesn’t do the patient much good for their gait cycle, either. This foot presentation impairs gait mechanics for several reasons, but the biggest issue is that the patient loses the ability to propel themselves forward with a strong plantarflexor force at toe-off due to altered length-tension relationships in the muscles and tissues and altered joint angles and mechanics. Lack of forward propulsion leads to many biomechanical faults in the gait cycle (hip pain, knee pain, back pain) and can significantly increase the risk of falling. Further, it results in compensations that slow gait speed, which has an overall impact on all-cause mortality. Ya’ll… this is serious. And we haven’t even gotten to the worst part of Charcot foot yet.


Overall, a lacking neurovascular supply to bone results in impaired bone health and could result in collapse. That is seen in Charcot foot, where the midfoot joints collapse and the navicular literally sits on the ground. This then causes increased pressure (which the patient cannot feel) and often results in ulcers. Other bones are affected, too. Avascular necrosis is more common in patients with diabetes and can impact the femoral head, humeral head, several portions of the tibia, and many other locations in the body. When the bone becomes necrotic, it cannot provide the structural support the body requires, and will often fracture under less stress than normal.


Toenails are a rough topic for many people with diabetes. Similar to all the other tissues, the nails can not get good circulation. Because they are a protective feature for our foot, they thicken to provide better protection with less supply. This results in nails that are very hard to cut, and often grow in odd shapes and angles. These nails can result in it being very hard to wear normal shoes and further ulcers of the feet can result from improper wear. These toenails also can get infected easier as they collect more debris and don’t receive the immune system warriors as well due to poor circulation.


Where Does Physical Therapy Come In?

So many places!

The foot inspection is a critical part of my evaluation whenever I see a patient with diabetes. Checking for redness, callouses, points of pressure, deformities, circulation, and sensation are all top of my mind. If my patient’s feet are impaired, they don’t have a safe and solid base for movement, so I have to work on that first.

Your first step should be education. Many patients with diabetes don’t know they are having problems with their feet because they can’t feel them. But, if they haven’t lost feeling yet, you can educate them on the signs to look out for and how to delay or prevent these degenerative changes from happening. The education we talked about in Part 1 of this post around managing blood glucose properly, diet, and staying active are key. But there are several more areas we can help.

Break out the hand mirror and start teaching people how to look at their feet! We talked about so many tissues that can be seen from the outside, so have your patient look at their feet every day to inspect for wounds, callouses, signs of pressure, and skin breakdown. Changes in bone structure can be seen from the outside and blood supply can be checked with a simple capillary refill test. Have them clean their feet as part of the process. This may require some special tools but will help prevent infection and callous formation.

Photo by Andrea Piacquadio on

Sensation testing is pretty key here. I talked a lot about nervous system testing in this post, but for patients with diabetes, we really want to focus on protective sensation. Break out that monofilament kit and get to poking! Make sure to follow a standardized method (there are lots of options out there), and test both feet! Light touch is great and will tell you a lot about the patient’s ability to detect injury, but don’t forget about other sensations like we talked about earlier. Proprioception and kinesthesia should also be tested and, finally, you should be doing a very thorough balance assessment.

Another great role for the PT performing the foot inspection is to help the patient get shoes! We talked so much in this post about the importance of well-fitting shoes that are to be worn all the time. But patients don’t want to wear shoes all the time if they don’t fit well!. Thankfully, Medicare, and some other payers have agreed and offer patients with diabetes a shoe benefit. Let’s check that out.


In addition to looking at the foot, you also have to look at the shoe. How old is it? How worn is it? Does it fit right? Is it the right size? Does it accommodate swelling? Check out the wear pattern on the bottom and take a peek inside. Pull out the insert and look at the wear pattern on it. Compare that to the foot! Are there areas of redness on the foot that correspond to points of pressure in the shoe? Could the shoe be providing better support for their foot than it is?

Now, let’s get more functional: Can the patient put the shoe on and take it off themselves? Do they need some equipment for that? Can they tie a shoe? Do they need to accommodate an AFO? These are all things we should be thinking about when looking at shoes for patients with diabetes.

Photo by Zain Ali on

Based on Medicare guidelines, patients who are diabetic and meet certain criteria are eligible for a pair of custom/supportive shoes and inserts for those shoes every year. There are some strict criteria around this but there are several roles for us to play in this process. Especially in patients who are homebound or in communal care settings, they may not be able to get out and see a physician for their feet regularly, but we see the folks all the time! So here’s how we can help.

The Medicare criteria for diabetic shoes and inserts require that the patient have a presentation including one or more of the following:

  1. Previous amputation of the other foot, or part of either foot, or
  2. History of previous foot ulceration of either foot, or
  3. History of pre-ulcerative calluses of either foot, or
  4. Peripheral neuropathy with evidence of callus formation of either foot, or
  5. Foot deformity of either foot, or
  6. Poor circulation in either foot

Now, those all sound like things we have already talked about, don’t they? We cannot certify the need for the diabetic shoes under Medicare, but we can notify the physician of the issues and that the patient qualifies based on our physical exam findings. The patient still needs an in-person visit with the doctor at some point, but we can get to that when they are able!

Photo by Dazzle Jam on

And tell your patient not to worry, they don’t HAVE to get those terrible bulky diabetic shoes if they don’t want to. There are some requirements around what shoes are acceptable, but patients are often able to get a really supportive athletic shoe instead.

Further requirements also talk about a “supplier.” Now, if you are a PT who is also an orthotist, you can be that supplier! Maybe you work for a company that sells diabetic shoes? You can also be that supplier! The supplier is required to perform an assessment for the shoes and assess the fit of the shoes upon delivery and make any modifications necessary to the fit if needed (for those custom-molded pieces).

  1. Prior to selecting the specific items that will be provided, the supplier must conduct and document an in-person evaluation of the beneficiary.
  2. At the time of in-person delivery to the beneficiary of the items selected, the supplier must conduct an objective assessment of the fit of the shoe and inserts and document the results. A beneficiary’s subjective statements regarding fit as the sole documentation of the in-person delivery does not meet this criterion.

This is where that team piece comes in. Diabetes impacts every system in the body, so it takes a team to manage it properly. You need someone who can get to the patient, assess their feet, work with you on their specific needs for their mobility, and get the proper devices to the patient as soon as possible to prevent any further injury. Speaking of the team, don’t try to cut those toenails yourself unless you are trained too! Get a podiatrist on board as soon as possible to make sure those feet are in tip-top shape from every angle!

What if You’re Too Late?

I had an amazing patient a long time ago who referred to all his different body parts as car parts. When he came to see me the first time in our little outpatient rural clinic that treated everything, he said he had a flat tire. Turns out his little toe on one foot was black. It was just dead. There was nothing else to it. He had significant vascular damage and neurological impairment due to his uncontrolled diabetes, so he was referred for surgery for him. He talked about losing a lugnut, but it otherwise didn’t bother him much because he couldn’t feel it.

You won’t always get there in time. Know when things can’t be fixed and know when they are beyond your scope and need further care, like antibiotics or vascular surgery.

Photo by cottonbro on

We will often see a person after their amputation, whether it be a toe, like my friend above, a part of the foot, or the whole foot itself. The goal then becomes to preserve what is left. If the whole foot is gone, do whatever you can to save the other foot. If only the toe is gone, save the others. The higher the amputation goes, the harder the recovery will be, especially considering all the other factors we talked about above that come along with diabetes.

I know it may seem like I’m missing the most obvious piece of the puzzle here (where is the exercise???) but I’m getting to that. Diabetes is a complex beast and there are many places where we fit in. Keep checking back!

What is YOUR role in helping patients get diabetic shoes? Have you had a patient lose a lugnut or other carpart? Tell me in the comments!

Get new content delivered directly to your inbox.

More Reads from the Chronic Disease Management Series


Cleveland Clinic Staff. (2019). Charcot Foot.

Medicare Coverage Database. (2022). Therapeutic Shoes for Diabetics. Centers for Medicare and Medicaid Services.

Follow @DoctorBthePT on Twitter for regular updates!

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Follow @DoctorBthePT on Twitter for regular updates!

Treating Long-COVID: Part 2

So, like I mentioned in Part 1 of this post, I might get some hate mail for this. Keep in mind that research is constantly changing around Long-COVID and that I’m just trying to stick with what the research tells us. I know some or many may not agree, but these aren’t my opinions, they are evidence-based statements and I’m going to keep them that way. I’ll update this information as the evidence changes so keep checking back!

Post-COVID without PEM

It is important to remember that, although ANY case of COVID-19 can eventually develop into Long-COVID, not all of them do. Not everyone experiences diffuse vascular damage. We don’t know what makes the difference between who does and who does not get Long-COVID. We do know that it is important to monitor all post-COVID patients for symptoms of Long-COVID.

“Before recommending physical activity (including exercise or sport) as rehabilitation interventions for people living with Long COVID, individuals should be screened for post-exertional symptom exacerbation through careful monitoring of signs and symptoms both during and in the days following increased physical activity, with continued monitoring in response to any physical activity interventions.”

World Physiotherapy, 2021

So how do you screen for Long-COVID or PEM, then? According to World Physiotherapy, here’s what to look for:

  • Patient-specific symptom exacerbation 12-48 hours after exercise or cognitive strain that lasts days or longer
  • Objective, measurable decline in aerobic capacity and anaerobic threshold on serial cardiopulmonary exercise testing due to neuroimmmune and metabolic dysregulation
Photo by Anna Shvets on

That means you have to know what baseline symptoms are and what symptoms are the most often exacerbated. This is likely to be different for each patient, but the most likely ones are generalized fatigue and decreased cognitive function/fogginess. You can read more about that in Part 1.

This also means you need to have a baseline test of some kind to demonstrate this “objective, measurable decline.” But that’s problematic, isn’t it? Patients with Long-COVID can’t often tolerate an official cardiopulmonary exercise test. So, you’ll have to talk to them about how much activity they can tolerate and if there is a significant change in that level of activity.

Post-COVID Exercise Prescription

Here is where I’m going to get hate mail.

But what about the exercise? Isn’t well-prescribed exercise the best possible intervention to expedite the healing of damaged vasculature? Yes. Yes it is. We know that from hundreds, if not thousands, of studies on vascular diseases and diseases that cause vascular damage. So, can a patient who is post-COVID without post-exertional malaise exercise to the extent of their ability? According to the evidence, the answer is YES! Here’s the breakdown.

Photo by Andrea Piacquadio on

Remember, not ALL cases of Long-COVID come with PEM, PEM is just one symptom. So, if your patient doesn’t have PEM, exercise may be very helpful for them. It might be a slow start, and that’s ok. Remember that COVID-19 is a systemic vasculitis. You have miles of vasculature in your body, and that’s miles of potential damage. That damage takes time to heal and the greater the extent of the damage, the longer it may take. That systemic vasculitis comes along with the potential for post-exertional symptom exacerbation which you DO NOT want happening because of the exercise you prescribed. You can prescribe activity and you can prescribe exercise, but you have to make sure that is within the patient’s ability and goals.

Well, that’s great! But what kind of exercise is the best exercise for people after they have COVID-19? The answer may shock you…

High-Intensity Interval Training

Yep, I know, I know. But it’s true. High-intensity interval training has some of the strongest evidence for people with vascular disease. It also has very strong evidence for people with vascular disease who has a host of comorbidities. However, this high-intensity interval training isn’t the same thing you see in infomercials, fitness classes, or gyms. The design and framework are the same but it is used differently, with skilled precision and constant monitoring.

Some evidence translated from pre-COVID vascular diseases indicates that using an inverse design to high-intensity interval training is a great place to start. This is because high-intensity interval training has the strongest evidence for providing anti-inflammatory effects by decreasing the production of inflammatory factors and increasing the clearance of inflammatory substances already in the body. High-intensity interval training does this better than moderate-intensity continuous exercise. High-intensity interval training is also more effective at promoting the healing of vascular and cardiac tissues and can even induce left ventricular remodeling.

Patients with systemic vasculitis secondary to COVID-19 have A LOT of inflammatory junk in their systems. Their entire vascular system is damaged meaning that there are byproducts of the cellular damage, cellular metabolism, and apoptosis circulating everywhere and the load has exceeded the body’s natural ability to clear it. High-intensity interval training can give your patient the extra assistance they need, but only if you design their programs properly. Designing programs that have longer rest intervals and shorter work intervals, at least to start with, has shown to be more effective for patients post-COVID. These programs should include functional and meaningful movements and activities so that the daily workload can be built into the exercise program to prevent over-taxing the system. I’ve heard recent patient stories that report heart rates over 200 beats per minute simply vacuuming, or walking up a single flight of stairs! Don’t be afraid to progress, but let the patient’s symptoms and tolerance lead you.

Photo by Roger Brown on

We learned in Part 1 of this post that you cannot calculate max heart rate the same way for patients post-COVID as you do for patients who haven’t had COVID. People who have the cardiac effects of long-COVID (elevated heart rate at rest and exaggerated heart rate response to minimal activity) may be on medications, like beta-blockers, to control their heart rate. That means that determining what “high” intensity is for that specific patient includes hitting a specific heart rate window. It also means that the “low” intensity target is also a very specific window. And there is no way to know you hit those windows unless you are constantly monitoring vitals before, during, and after exercise, and also with recovery. Make sure to go back to Part 1 and read the specifics on calculating max heart rate in patients with long-COVID!

Don’t forget about the other vitals, either. Many patients post-COVID have excessive respiratory rates, but normal heart rates, with activity. This should be equally concerning and should tell you they need a different exertion scale! Keep your eyes on the blood pressures and pulse oximeter readings, also. You have to keep the big picture in front of you at all times!

Take-Home Points:

Calculate heart rate max and target heart rate zones properly.
Design HIIT programs to match those heart rate zones.
Monitor vitals to ensure you are reaching, but not exceeding the heart rate zones.
Use the right exertional scales for your patient.
Always be assessing symptoms!

Evidence for ME/CFS

PLEASE… Do NOT throw the tomatoes at the messenger. The evidence for post-viral fatigue / myalgic encephalomyelitis / chronic fatigue syndrome even prior to COVID-19 supported the use of high-intensity interval training with this population IF they do not have post-exertional malaise. Remember, post-exertional malaise is just one of many symptoms of these post-viral conditions and DOES NOT happen to every patient who contracts them.

Photo by Jonathan Borba on

Specifically, there is evidence to support high-intensity interval training as a more tolerable method of exercise in patients with chronic fatigue syndrome because it does not exacerbate fatigue like moderate-intensity continuous exercise. It is thought that the shorter bursts of activity, followed by either complete rest or active rest are more tolerable than longer bouts of exercise because this design allows the body to have intermittent recovery periods while working. This evidence goes on to report that high-intensity interval training can actually help patients who experience other symptoms of chronic fatigue syndrome, such as insomnia and decreased physical function.

Take-home points:

Not every case of ME/CFS or post-viral syndrome or long-COVID will have the same presentation and/or symptoms.
Not every person who has ME/CFS has post-exertional malaise.
Not every person will be intolerant of physical activity.
Let the symptoms (and the patient) be your guide.
Refer to Part 1 for more info on other options besides exercise.

Can you take this back to the clinic tomorrow? Will you take this back to the clinic tomorrow? Let me know in the comments.

Get new content delivered directly to your inbox.

Follow @DoctorBthePT on Twitter for regular updates!


Sandler, C. X., Lloyd, A. R., & Barry, B. K. (2016). Fatigue Exacerbation by Interval or Continuous Exercise in Chronic Fatigue Syndrome. Medicine and science in sports and exercise48(10), 1875-1885.

Foged, F., Rasmussen, I. E., Budde, J. B., Rasmussen, R. S., Rasmussen, V., Lyngbæk, M., … & Christensen, R. H. (2021). Fidelity, tolerability and safety of acute high-intensity interval training after hospitalisation for COVID-19: a randomised cross-over trial. BMJ open sport & exercise medicine7(3), e001156.

Larun, L., Brurberg, K. G., Odgaard-Jensen, J., & Price, J. R. (2017). Exercise therapy for chronic fatigue syndrome. The Cochrane database of systematic reviews4(4), CD003200.

Keech, A., Way, K., Holgate, K., Fildes, J., Indraratna, P., & Yu, J. (2021). HIIT for post-COVID patients within cardiac rehabilitation: Response to letter to the editor. International journal of cardiology322, 291–292.

Nelson, M. J., Bahl, J. S., Buckley, J. D., Thomson, R. L., & Davison, K. (2019). Evidence of altered cardiac autonomic regulation in myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review and meta-analysis. Medicine98(43), e17600.

Décary, S., Gaboury, I., Poirier, S., Garcia, C., Simpson, S., Bull, M., … & Daigle, F. (2021). Humility and acceptance: working within our limits with long covid and myalgic encephalomyelitis/chronic fatigue syndrome. journal of orthopaedic & sports physical therapy51(5), 197-200.

Christensen RH and Berg RMG (2021) Vascular Inflammation as a Therapeutic Target in COVID-19 “Long Haulers”: HIITing the Spot? Front. Cardiovasc. Med. 8:643626. doi: 10.3389/fcvm.2021.643626

Brockway, K., Ayers, L., Shoemaker, M. (2022). HIIT-ing Your Target: Applying High-Intensity Interval Training in Special Populations. APTA Cardiovascular and Pulmonary Academy. Presentation at APTA Combined Sections Meeting, San Antonio, TX.

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Follow @DoctorBthePT on Twitter for regular updates!

Treating Long-COVID: Part 1

I’m sure you have been hearing a lot lately about Long COVID. You may have heard it called many different things: Long-COVID, Post-COVID Syndrome, Myalgic Encephalomyelitis, Post-Viral Fatigue Syndrome, Chronic Fatigue Syndrome, ME/CFS, long-haul COVID, or post-exertional malaise (really a symptom, or PESE – post-exertional symptom exacerbation). These terms are not interchangeable, but in the conversations on these conditions, they are all frequently mentioned. I’m going to give you a brief overview of what you need to know about Long-COVID and what role PTs play in managing this condition.

First, new evidence suggests that around 55% of all people who have had COVID-19 will develop at least one of the following symptoms. MORE THAN HALF of all people who have had COVID-19. Yes, You read that correctly and you can go read the article yourself (citation below: Taquet, 2021). Long-COVID has been associated with a host of symptoms that result from the initial viral illness regardless of how impaired or sick the individual became because of it. What that means is that someone could develop Long-COVID after an asymptomatic bout of COVID-19. Some sources estimate that Long-COVID affects about one-quarter to one-third of people who have had COVID-19. Nearly one-third of all people who experience long-COVID had no symptoms of active COVID-19 infection.

Photo by Nandhu Kumar on

Most people who experience Long-COVID show symptoms of fatigue and shortness of breath but, according to the Mayo Clinic, many other symptoms have also been associated with Long-COVID:

  • Cough
  • Joint pain
  • Chest pain
  • Memory, concentration or sleep problems
  • Muscle pain or headache
  • Fast or pounding heartbeat
  • Loss of smell or taste
  • Abdominal discomfort
  • Depression or anxiety
  • Fever
  • Dizziness when you stand
  • Worsened symptoms after physical or mental activities

That last one is where we are going to spend some time. Worsened symptoms after physical or mental exertion is what has been termed “post-exertional malaise, (PEM)” or “post-exertional symptom exacerbation, (PESE)” and is a symptom that can and should significantly impact your rehabilitation plan and exercise prescription for patients with long-COVID.

Long-COVID with PEM

Rehabilitation for patients with Long-COVID has been a troublesome and confusing concept, as these patients do not and cannot progress like the typical respiratory failure patients do in therapy. The reason for this (we think, as evidence is frequently developing) is the diffuse endothelial damage of the vascular system throughout the entire body secondary to COVID-19 infection. The vasculature in the lungs can be significantly damaged producing impaired ventilation/perfusion ratios. The endothelium cannot produce or release the chemicals necessary for efficient or effective vasodilation to increase blood supply to the tissues. This produces impaired vascular return to the heart. The brain cannot get enough oxygen because of these other faults. In addition, there are many effects of this diffuse vascular damage that we can’t completely account for, but that seriously impact overall physiological function, such as the increased presence and reduced ability to clear inflammatory substances. These issues, among others, contribute to the increased incidence of clotting.

But the endothelium is a two-way street. Things don’t just pass into the bloodstream, but also pass out of it through this single-cell layer. And when it isn’t functioning properly, all those things that need to get out just can’t. This results in a build-up of inflammatory substances like cytokines and interleukin-6. Inability to clear these inflammatory factors contribute to ongoing damage to the endothelium, creating an iterative process.

And, let’s not forget that some treatments for COVID-19 can actually produce Long-COVID symptoms. Yep, that’s right. Some of the treatments for COVID can cause Long-COVID-type symptoms. Specifically, monoclonal antibody treatment, which has been around for a while, is known to be cardiotoxic. You can read more about how to monitor patients who have received this treatment HERE.

If your patient is experiencing post-exertional malaise or symptom exacerbation secondary to Long-COVID, you should not be pushing them to the point of developing this malaise, as it can take days or weeks to recover from a single bout of the activity or mental exertion, if they are able to recover at all. Your PT evaluation could be all the exertion it takes to put these folks out for a week. But that doesn’t mean there is nothing we can do. Physical Therapists can hold many important roles when managing patients with post-exertional malaise. Let’s talk about some of those roles.

Managing Patients with Post-Exertional Malaise
  1. Do No Harm: Our first job, as Decrary and colleagues (2021) so eloquently stated, is to do no harm. But, how do we go about our job and not do harm to these patients? Take some steps to educate yourself, first. There are several continuing education courses to help you out that revolve around treating patients with post-viral fatigue syndromes and chronic fatigue syndrome. We need to see this as similar to trauma-informed care. Many of these patients have experienced trauma in some form, whether that be within the experience of severe COVID and being hospitalized for a long period of time, or because they feel they have been dismissed by other healthcare providers. Either way, approaching management through a trauma-informed lens can be helpful.
  2. Validate and Advocate: Physical Therapists hold the tools to validate and advocate for our patients. We can assess their physiological responses to activity, because that is what we are trained to do, and report them to the medical team to validate concerns and help guide treatment. We can be the evidence-supported voice for our patients, improving their care and their experience.
  3. Stop. Rest. Pace. BUT Do It Right!: Decrary and colleagues (2021) released the Stop. Rest. Pace. Guidelines for treating patients with Long-COVID (and other post-viral illnesses). Implementing these guidelines into our practice is critical. But it’s really not that simple. If you’ve ever visited the ME/CFS Twitter or Facebook groups or spoken to people who have ME/CFS, they will often tell you that they’ve tried Physical Therapy, and gotten worse. They know we exist and they are told we can help, but we just aren’t doing it to the best of our ability. In speaking with these folks, that is really because we aren’t teaching ALL of the Stop. Rest. Pace. concepts that we could be teaching.

    The biggest gap in the education we provide seems to be education on activity pacing. This is an area where we should be the experts. We should know how to pace out activity to help a patient safely complete a 6-minute walk test or safely finish a marathon, but we aren’t translating those concepts to patients with Long-COVID. Pacing applies to the total amount of activity a person has the ability to perform over the course of a day, not just for exercise, but for every single thing they have to do, from showering to dressing to meal prep to driving. If that amount of energy (both physical AND cognitive) significantly decreases, we need to help them pace out their day. These are the basics of energy conservation.

All of this doesn’t mean that you can’t make progress. The goal of Stop. Rest. Pace. is to allow for healing time. These patients have some major healing to do for their entire vascular system and you have to keep them active to facilitate that healing. Encourage them, support mental health and faith-based healing, and educate them on a diet that supports tissue healing and reduces inflammation. As they heal, introduce them to low-level activities like beginner yoga, walking, or stretching, and consider injury prevention techniques. Remember that learning novel activities increases the mental load as well as the physical load, so may produce fatigue faster than familiar activities. Therefore, if they used to enjoy a particular activity, try that one, or an adapted version of it first.

Photo by Negative Space on
Energy Charts

Adding a visual can help your patient see this concept. Let your patients lead by having them rank activities they have to perform by how much energy it takes to do each one. Maybe brushing their teeth takes 3 energy units compared to driving to work which takes 6 energy units. Make a chart with these values and ask them how many they can do before they are exhausted or before they know they will experience fatigue symptoms. Use that total number to help them build their day with activities that add up to less than that total number so they aren’t pushing their limits.
Allow them to make choices about what activities they put in their day.

Here’s the shock-value statement: There may be no room for your exercise program. You’ll have to adapt.

These energy charts are a concept I’ve often used for patients who experience chemo or cancer-related fatigue. The visual representation of activities helps to picture an entire day, build in rest breaks, and prevent fatigue.

Patients will make value choices that surprise you, so be prepared.
Use this to establish your plan of care and write goals for these patients.

Finally, you need to reconsider what YOU think of as rest. This may not be what your patients view as rest. They may not live in a place where they can even achieve physical and mental rest. They may hold a job where they feel they cannot achieve rest or cannot take the time off to get the rest they need. They may have used all their PTO and sick time in the hospital. Ask your patients what they consider rest and help them problem solve how they can achieve that.

You can all tell from previous posts that I’m a pusher. I’m usually the one pushing people further, physically and mentally, than they are otherwise willing to go. Even if I can achieve a fraction more today than I did yesterday, I’ll push for it.
BUT NOT HERE. I’ve drawn my line in the sand. This is where we have to think differently. Until that vascular system properly heals, we have to think about the acute phases of tissue healing, protection, providing building blocks, and ensuring the basic levels of function are maintained.

In the next post, I will go into the details on how and why to provide exercise and activity-based interventions for your patients who are post-COVID but without post-exertional malaise. This one might get me some hate mail, so stay tuned!

Do you see patients with Long-COVID? What is the most common symptom they report? Tell me in the comments!

Get new content delivered directly to your inbox.

Follow @DoctorBthePT on Twitter for regular updates!


Taquet, M., Dercon, Q., Luciano, S., Geddes, J. R., Husain, M., & Harrison, P. J. (2021). Incidence, co-occurrence, and evolution of long-COVID features: A 6-month retrospective cohort study of 273,618 survivors of COVID-19. PLoS medicine18(9), e1003773.

Décary, S., Gaboury, I., Poirier, S., Garcia, C., Simpson, S., Bull, M., … & Daigle, F. (2021). Humility and acceptance: working within our limits with long covid and myalgic encephalomyelitis/chronic fatigue syndrome. journal of orthopaedic & sports physical therapy51(5), 197-200.

Mayo Clinic Staff. (2021, Oct 21). COVID-19: Long-term effects. Mayo Clinic.

(No Author). (2021, March 30). Studies show long-haul COVID afflicts 1 in 4 COVID-19 patients, regardless of severity. UC Davis Health.

Centers for Disease Control and Prevention (CDC). (2021, January 27). What is ME/CFS? Myalgic encephalomyelitis/chronic fatigue syndrome.

World Physiotherapy. World Physiotherapy Response to COVID-19 Briefing Paper 9. Safe rehabilitation approaches for people living with Long COVID: physical activity and exercise. London, UK: World Physiotherapy; 2021

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Follow @DoctorBthePT on Twitter for regular updates!

That Beautiful Teaching Moment: ABI

If you’ve ever had a student with you for a clinical rotation, you know the feeling of just hoping for that beautiful teaching moment, the one that just opens up naturally. You look for the moment when you can dig a little deeper in to your student’s reasoning skills and let them flex their therapy muscles a little bit harder than usual. It’s one of those moments where they know the right answer, but you get to back track them through the process that they didn’t even know they went through to get there.

I had a wonderful moment like that when I was seeing a patient for at home for sepsis. He had septic pneumonia (same one I mentioned here) and had been intubated and ventilated for several days. He had a complex medical history including DM2, CAD, PVD, and CKD, among other things, but was really just severely deconditioned due to PICS. He came home using a 4-pt walker and 6 L/min of supplemental oxygen. His prior level of function was fishing and doing yard work daily without a device or oxygen. He had rarely ever been sick in his life, and I had the honor of restoring this man to health.

It only took 8 weeks to bring him back and High-Intensity Interval Training was the key factor in his recovery, along with two daughters who ensured 100% compliance with his home program! It was the perfect set up. My student entered on visit number two. She reviewed my evaluation and knew we were going in to a tough case, but she took it in stride. She took charge of his HIIT program and drove the show. Her progressions were beautiful and we worked together to titrate his supplemental oxygen down over time to the point where he no longer even needed it. But the REALLY beautiful teaching moment was the day he came down with gout.

Why on earth would I say gout was beautiful??? It was really the perfect opportunity to integrate her differential diagnosis skills in a patient case that was flowing all too easily. One day, we showed up and our patient couldn’t walk. He was in pain. These things had never been an issue before. We didn’t have a diagnosis of gout at the time, but having seen it plenty of times before, I had narrowed it down fairly quickly. I asked her to do an evaluation of his affected ankle and she did the usual: ROM, swelling, joint mobility… There were some superficial skin wounds so we couldn’t totally rule out cellulitis and she wanted him to see the doctor, so we scheduled him a visit for the next day and we would return the following day for our usual visit.

We got back in the car and I asked her, “so what was your differential list?” I sat and listened quietly as she gave me her list of diagnoses and reasons for each one, but she hadn’t mentioned gout. I attempted to discuss some of the findings with her in relevance to the patient’s age and comorbidities, but still no gout. We discussed it later that day, still no gout. I asked her to go home keep thinking about her findings.

Photo by Pixabay on

Two days later when we went back, I brought it up on the drive there and asked her if she had changed her mind. She hadn’t come up with anything new and was settled on cellulitis. As we were pulling in to the driveway, I said to her, “it’s gout.” She looked confused and then asked why I thought that. To be completely honest, I should have just said “gestalt” because that was the original reason. But instead, I explained the symptoms in the presence of the patient age and history, and lack of reason for infection (no fever, etc). She nodded and was quietly thinking it over as we walked in to the house.

He had a new prescription for an antibiotic so I was a bit concerned I had been thrown off by an angry cellulitis, but then I asked the patient to tell me about his appointment. He said the doctor told him he couldn’t rule out cellulitis so gave him the antibiotic, but thought it was probably gout. (Phew!)

So, of course, my next step was to ask my student what we could do for our patient to help with his pain and improve his walking while this gout was flaring. Her answer was perfect: ice, elevation, and compression. But wait… what about his medical history? We had just discussed in the car how he had PVD, CAD, and diabetes. I followed her answer with a question, “how do you know it is safe to use compression?” And this is where the teaching moment happened!

I could see in her eyes that she knew where I was going and that not all people can have compression. I could see in her eyes that she even knew the reason I was asking, since we had just talked about his history in the car. But she didn’t know how to know if it was safe. And this, my friends, is where I got to show my student how and why you would perform an ABI. (AND I WAS SO EXCITED!)

ABI stands for Ankle Brachial Index. It is the systolic blood pressure taken at the ankle divided by the systolic blood pressure taken at the brachium. (Ankle over Brachial) An ABI will tell you how well the arteries are able to circulate oxygen and nutrients to the tissues of that lower extremity.

So why would YOU need to do an ABI?

Yes, I said NEED to do. This is for the safety of your patients. You can’t just be throwing compression at everyone who has edema. There is a clinical decision making process that may require further testing before that can be deemed appropriate. Here’s a few reasons to do ABI testing:

  • If you are planning on providing compression to lower extremity of a patient with PVD or PAD (or any risk factors for these conditions -see below)
  • If you suspect serious PVD/PAD and want to quantify it or monitor progression over longer periods of time (per the Cleveland Clinic, ABI is used for this regularly)
  • If your patient is having difficulty healing lower extremity wounds
  • Your patient reports increased pain in the legs with elevation which is relieved with dependent positioning
  • Your patient reports pain in the legs with activity

This particular test requires some special equipment. I was carrying a Doppler at the time because I had been seeing a couple LVAD patients on and off and needed to be prepared so I retrieved it from my trunk and off we went. If you don’t have access to a doppler, you can use a an automated BP cuff if you are absolutely sure it is accurately calibrated. There is evidence to support this, and it actually increases the specificity of testing significantly.

Speaking of clinometric properties:

When using a Doppler: ABI sensitivity is 95% and specificity is 56% for diagnosis of peripheral artery disease (PAD).
When using an automated blood pressure cuff: ABI sensitivity is 97%, and specificity is 89% for diagnosis of peripheral artery disease (PAD).

Nothing like a good high-specificity AND high-sensitivity test for you to add to your tool box!

As I was having the patient rest in supine for a few minutes to ensure measurement accuracy, I was able to explain the objective findings associated with PAD including:

  • Lack of hair growth on the legs
  • Skin that feels cold and/or clammy and may be pale or mottled in appearance
  • PMHx including diabetes, CAD, high blood pressure, high cholesterol (all of which my patient was on medication for), smoking, and increased age
  • Presence of a gangrenous appendage

That last one is a little weird, but I actually did ABI testing on a patient who had a finger that was gangrenous from the DIP distally. It was only one finger, but his ABI was 0.48. His doctor was incredibly grateful for this information and he was scheduled for surgery shortly after, not only to remove the finger, but also to improve his circulation by opening up the vasculature.

How do you do an ABI?

If you can take a blood pressure, you can do an ABI. It does NOT require a special order to be performed. Like I said, you are just taking blood pressures. I’ve taken blood pressure on legs for patients that don’t have arms and I didn’t need an order for that either! However, performing an ABI is a billable service through Medicare, so if you want to get some referrals going for this service, that’s cool, too. (CPT code 93922 (coded twice, once for UEs and once for LEs, typically requires a -59 modifier) and must be in conjunction with a full evaluation or other procedures for reimbursement). (<–DISCLAIMER: I am no coding expert! Please carefully read the descriptions to ensure you are coding properly!)

  1. Have your patient lay supine and rest for 5 minutes, just like you would if you were doing orthostatics.
  2. Take their normal brachial blood pressure and record your number.
  3. Take out your Doppler and find that dorsalis pedis artery (or posterior tibial).
  1. Get the cuff of your patients leg and inflate until you no longer hear the dorsalis pedis, then go up another 20 mmHG just like you should when taking a typical blood pressure.Release the pressure slowly (just like normal) and record your systolic result (the number at which you hear the dorsalis pedis/posterior tibial flow return).
  2. Repeat on the other leg and then arm.
  3. Divide the highest ankle systolic by the highest brachial systolic to get your result (See worksheet)

To make your math even more simple, you can download this worksheet from Project Lead the Way (2014):

Or if that doesn’t work, there is a comprehensive worksheet and instruction set here.

Ok…. so now what?

Well, there are some normative values to which you need to compare your result

  • Normal: 1.0 to 1.3
  • Borderline PAD: 0.9 to 1.0
  • PAD: 0.9 or less
  • Moderate PAD: 0.4 to 0.7
  • Severe PAD: less than 0.4
  • If you get a number greater than 1.3, this indicates the arteries have become rigid. Arterial calcification is typically at fault, thanks to diabetes.

If you are seeing numbers in the severe category, you can anticipate this patient needing some more extensive interventions IF they are medically stable enough to receive them. However, if their vasculature is functioning that poorly, they may not be stable enough. They would also NOT be a candidate for use of compression to treat whatever it is you are looking to treat, as they would be at a significantly increased risk of losing complete blood flow to their extremity. Needless to say, this should mean you are calling the doctor.

It should be mentioned that it is not your role to interpret ABI information. You can and should be assessing this information, but it is the physician’s call about what to do with it, so report it! Just like with orthostatics, this information is very important in the overall clinical and medical picture of the patient, so doctors want to know!

Thankfully, our patient was giving us 1.1 and 1.2 so he was not at risk for adverse events with proper use of compression. We utilized an ACE wrap and his daughter bought him some low level compression stocking which worked beautifully once we showed them how to put them on him. His gout was fleeting, only a few days, and he was back on track in no time.

How often do you treat patient who have PAD? What interventions do they typically benefit most from? Tell me about it in the comments!

CO2 Retainers

Getting sciencey now! The science behind COPD and oxygen to help lead you right!


Something went wrong. Please refresh the page and/or try again.

Follow my blog for more!


Chaudru, S., de Müllenheim, P. Y., Le Faucheur, A., Kaladji, A., Jaquinandi, V., Mahe, G. (2015). Training to Perform Ankle-Brachial Index: Systematic Review and Perspectives to Improve Teaching and Learning. European Journal of Vascular and Endovascular Surgery. 51. 10.1016/j.ejvs.2015.09.005.

Cleveland Clinic. (2019). Ankle Brachial Index. Retrieved from

Crawford, F., Welch, K., Andras, A., & Chappell, F. M. (2016). Ankle brachial index for the diagnosis of lower limb peripheral arterial disease. The Cochrane database of systematic reviews9(9), CD010680.

Herráiz-Adillo, Á., Cavero-Redondo, I., Álvarez-Bueno, C., Martínez-Vizcaíno, V., Pozuelo-Carrascosa, D. P., & Notario-Pacheco, B. (2017). The accuracy of an oscillometric ankle-brachial index in the diagnosis of lower limb peripheral arterial disease: A systematic review and meta-analysis. International journal of clinical practice71(9), 10.1111/ijcp.12994.

Jitendra, M. (2020). Medical Coding Guide: Tips for Coding ABIs. American Medical Coding. Retrieve from

National Institutes of Health. (2020) National Heart, Lung, and Blood Institute: Peripheral Artery Disease. Retrieved from

Project Lead The Way. (2014). Human Body Systems Activity 4.3.5 Student Resource Sheet. Retrieved from

headline image credit

Follow @DoctorBthePT on Twitter for regular updates!

Home (Health) is Where the Heart Is

Dr. Rebekah Griffith, other wise known as The ED PT, interviewed Dr. B on all things patient care management and how PTs in the ED and Home Health PTs can work together to provide the best possible care for patients. We talked about the struggles we each face in managing complex patients and the roles we both play in emergency and first-line responders for patients in need.

Check us out on YouTube on her incredible Podcast: Admitted or Not, where she talks about all kinds of cases she sees as an ED PT and you get to guess if they were admitted or not! I was even able to give her a couple new ones!

Or you can listen to us here on Sounder on the Admitted or Not Podcast!

Either way you enjoy, just make sure you check out The ED PTs website to see all her cool stories, items, and courses! If you are interested in how ED PTs practice or you want to work in the ED, this is the place you need to be!

Follow @DoctorBthePT on Twitter for regular updates!

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Follow @DoctorBthePT on Twitter for regular updates!

Expanding Your Role, Fulfilling Your Scope

So now that you know how I feel about primary care PT, you need to know that this ties very closely with my practice. I have extensive experience in the treatment and management of patients with chronic disease. And when I say the treatment and management, I don’t mean that I went to their house and gave them some exercises, then left the rest to my (very skilled) assistant to handle until discharge. I mean that I saw them for a skilled home evaluation where we discussed the impact of their comorbidities on their life and function, performed evidence-based tests and outcome measures, and then created a care plan that included the patient’s goals as well as lifestyle modifications and education to control their diseases. Let’s be real: our profession is not following a protocol.

That means that there were evaluations where I talked about nothing but going to the bathroom safely and successfully. There were visits where I performed one single intervention for breathing (active cycle of breathing) and it took an hour. There were discharges that became reassessments because the patient started showing changes in their lung auscultation (new onset pneumonia). There were patients I saw for one diagnosis (a clavicle fracture) but treated and referred for another (undiagnosed Parkinson’s Disease). Sometimes I didn’t perform any interventions with the patient at all, but spent an hour with the caregiver trying to work things out. I have even spent an entire evaluation doing diabetic teaching on how to use a glucometer properly.

The chronic diseases I frequently treat include diabetes, congestive heart failure, chronic obstructive pulmonary disease, organ transplant (heart, lung(s), kidney, liver…), incontinence, hypertension, coronary artery disease, frailty, osteoporosis, chronic kidney disease, and end stage renal disease. I do not claim to be a neurological clinical specialist, but I do focus on the cardiovascular impairments associated with neurological conditions including orthostatic hypotension associated with Parkinson’s Disease, the vascular and cardiac impairments that cause cerebrovascular accidents, and the sequelae of falls such as bleeding (internal or external), brain injuries, and vestibular dysfunctions. And after COVID-19, we may even see a whole new subclass of chronic disease that we need to be addressing! Post-COVID syndrome, maybe?

Yes, I see total knee replacements, but I also see the chronic smoking that will delay healing due to intermittent tissue hypoxia and increased risk for infection. Yes, I see shoulder impingement, but I also see the eye aversion and reports of constant fatigue indicating depression and need for referral. Yes, I see low back pain, but I also see the urinary incontinence that so often is copresent and fully treatable.

Photo by Karolina Grabowska on

Did you know that the things you can do as a physical therapist to help manage and treat chronic disease are so small and so easy that you probably have just overlooked them? Let’s talk about those things:

  1. Ask about medications. I don’t mean asking if they take any. Yes, that is important, too, but ask if there have been any recent changes to their medications or if they started or stopped a medication lately. I have treated a patient for falls that happened because she was snowed on psych meds. Once we worked with her doctor to cut her dosage in half, she stopped falling.
    Most importantly, ask if your patient has taken their medications today!!! I cannot even count the number of times I have taken a blood pressure before starting a session to find severe hypertension and when I asked if the patient took their meds today, the answer is always “no, I forgot…” The only thing that tops that is how many times I have found severe hyperglycemia. Medication compliance is terrible generally with chronic disease, but, to be more specific for you:
    1. Patients with type two diabetes are noncompliant with medications up to 81% of the time.
    2. Patients taking medication for hypertension are noncompliant as often as 30% of the time.
  2. Ask about incontinence. Everyone will deny they have it so you need to find another way to ask. “Do you ever have any leakage when you cough or sneeze?” “Do you ever need to use incontinence products?” “Do you ever have to change your clothes mid-day due to leakage?” If you don’t get specific, you won’t get a useful answer. 80% of women and (possibly up to) 60% of men have some type of incontinence at some point in their lives. You may catch them as that point. Stress, urge, functional, and mixed incontinence can be fully treatable if you know they exist. We also know that urinary incontinence and constipation have a strong correlation with low back pain. If you can address either issue or both, back pain has a good chance of improving or being relieved. This is coming from someone who utilizes a fully mechanical approach to back pain like 90% of the time…
  3. Take Vitals. I should really just stop there… but I won’t (Ha! You should know me enough by now…). If you don’t know where you started, you don’t know where you’re at. If you take a blood pressure midway through your session, hey, that’s great! But that number doesn’t carry much weight if you don’t have something to compare it to. In the home care setting, when I have students, I always discuss with them the impact of chronic disease. I ask them, “How can you know if your patient is safe to get up out of their chair, today?” The answer is vitals. Not in the home care setting? Fine. Take them anyway. 90% of the time, you’ll see great numbers and everything will be fine, but that 10% is the part that matters. You may think you are pretty good at identifying people at risk for high blood pressure based on presentation. There is research to show that we are pretty good at figuring out who is really high risk and who is really not, but what about all those people who only have some risk factors (aka most of your patients)? If you need some guidance on those risk factors, the American Heart Association has constructed this table:
image credit
  1. Weigh your patients. This may sound a bit strange, but isn’t exercise one of the best treatments for just about everything including obesity? We know this. This isn’t new. Taking your patient’s weight can also be really helpful to track trends over time. But in the chronic disease management world, taking daily weights is necessary for management of congestive heart failure. (We talk more about that here!) It can also be really helpful when treating patients who undergo renal dialysis as fluid load directly impacts their ability to participate in physical therapy. Teaching your patient how to safely step up on and down from a scale is billable. Teaching your patient the importance of daily weights for preventing exacerbation is billable.
  2. Blood glucose monitoring. Your ability to do this may vary based on your state, but we all know the importance of blood glucose for exercise. If we don’t time our sessions properly, we end up with a patient passing out on us. If we do time them properly, we can actually (over time) decrease or eliminate the need for medication to manage blood glucose. Let’s talk about the logistics of this:
    1. To clear up the risk analysis: If your patient is already diabetic, they already have a physician’s order to check their blood glucose daily. If you ask them to or assist them in doing this prior to your session or during your session, you are in full compliance with this order. If you need to do this for your patient because they are unable, you are still in full compliance with this order. If your patient’s blood glucose is so low that they are fully unable to take their glucose themselves, are you going to sit there wondering if its ok while they fade away? No, of course not. You should probably be calling 911 at that point, but take their blood glucose. (Side note: please wear gloves.) Diabetic teaching is well within our scope of practice. So is diabetic intervention (aka exercise). PTs can even become certified diabetic educators.
    2. You cannot administer insulin if your patient’s blood glucose is too high unless you are trained to use the devices to do so and there is an order in place (if your patient is diabetic, there is an order in place, but you have to know how much, i.e. sliding scales and all that). You should be calling the physician for instruction if your patient cannot self-administer. You can, on the opposite end of the spectrum, give your patient food. You should have fast-acting sugars available in your clinic: juice, candy, applesauce… Even in outpatient clinics, I’ve given juice when I noticed the signs of hypoglycemia.
    3. What are safe parameters for blood glucose? I thought you’d never ask 🙂
      Too low: <50 mg/dL call physician/911 based on symptoms
      Too low for exercise: <70 mg/dL give sugar
      IDEAL RANGE: 100-250 mg/dL
      Too high for exercise: >250 mg/dL call physician, risk of ketoacidosis
      Too high: >350 mg/dL call physician/911 based on symptoms
      ***If doing an exercise class or performing exercise in long bouts (longer than 60 minutes) blood glucose should be checked every 30 minutes to ensure ongoing safety.

Ya’ll, that’s it. Really. All of these things are easy, quick, and well within our scope of practice. If we are claiming to provide primary care (which we definitely claim to do and actually do all the time!), we need to do the things that go along with it. You may be thinking that, even if these things are quick and easy, you can’t afford the extra minutes. When exercising someone with a chronic disease, you can’t afford not to spend the time. It could literally mean life or death in some cases. You may find out some surprising things! Maybe they’ve been struggling with loading needles in to their lancet device, and there’s an opportunity for some education and functional training.

The future of our profession may be providing exercise as an intervention for people with all kinds of chronic diseases like anxiety or depression. We already treat cancer and chronic pain. We need to be treating obesity and hypertension as a primary intervention. It will not be long before we are providing interventions for the prevention of a stroke based on a patient’s risk factors, so you better be good at taking blood pressures. Exercise prescription based on your genetic profile is already on its way where we will be able to predict the risk of a cardiovascular event at different intensities. You may even need to start incorporating a patient’s social determinants of health in to your plan of care if you haven’t already. Are you ready for this?

Well? Are you ready? Tell me how in the comments!

Follow my blog for more!


Goff, et al. (2014). ACC/AHA Guideline on the Assessment of
Cardiovascular Risk: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Circulation. Retrieved from

Hedegaard U, MS, Kjeldsen, Lene Juel, MS, PhD, Pottegård, Anton, MS, PhD, et al. Improving medication adherence in patients with hypertension: A randomized trial. Am J Med. 2015;128:1351-1361.

Mayo Clinic. (2020). Diabetes and exercise: when to monitor blood sugar. Retrieved from’re%20good%20to%20go,too%20high%20to%20exercise%20safely.

Polonsky W, Henry R. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Prefer Adherence.. 2016;10:1299-1307.

Follow @DoctorBthePT on Twitter for regular updates!

Primary Care PT

During her address to the House of Delegates this year, President Dunn quoted Mary McMillan‘s statements as she traveled back through the history of our profession…

“A physical therapist should keep up with the latest in her profession so that when new things come along she is aware of them, so that she may be of greatest service to her patients. She must believe in herself, for without this, others cannot have faith in her. She must have faith in herself, and that does not mean cocksureness, that all too frequently comes from ignorance. A physical therapist must never let her patients go without hope, and I do not mean false hope either, I mean real hope. Because hope helps to chase away fears. Of course, it’s not always easy. There will be hard knocks. It is the hard knocks that help to bring out the best timber in us. Who wants a soft job, anyway?”

Mary McMillan

Many of you know that I used to work in home health for several years. It was during my time in home health care that I learned the meaning of practicing to the fullest extent of my license. This is my second soap box (vitals are vital being the first), and I want to step up on to it for a minute.

If you’ve worked in home health, you know all too well how this goes. You admit the patient under the hospitalist or the primary care or whatever random doctor the patient names for you. You call them with your plan of care (Yes, this is what home care is required to do. No, it can’t just be in writing.) and they say something along the lines of, “I haven’t seen the patient in 3 years! I’m not signing for this,” or “I’m just the hospitalist/rehab doctor, I’m not signing for home care.” So now you are left to figure this out and hope your medical director will sign for services until the patient can be seen by someone for their face to face visit (another home care requirement). This means you are the only care provider managing this case. This means you are providing primary care in the home setting to some of the sickest patients.

COVID-19 has changed the way we practice. And if you don’t think so, you shouldn’t be practicing. PTs have had to step up and show what we are made of, what we can do, and how much we actually know. All I have to say is: It’s about time!

Photo by Pixabay on

More often than not, when patients return home from a subacute setting to the home setting, they are returning home with one or no caregivers. They may even be returning home with one or no other providers involved in their care (see example above). As physical therapists, practicing to the full scope of our education and license is going to be all the more important. We are now the front line against community spread of COVID-19. This doesn’t just apply to home health, but also to outpatient services. We are also the front line to prevent further health decline and hospital readmission. We are the front line to manage medication and assess health status. We are the front line to differentially diagnose whatever other impairments and conditions may be present. We are the front line to request assessment, tests, and other items that may assist us in patient care. We are the front line in screening for other health factors such as social determinants of health, safety in the home, and hidden health impairments.

So what does that mean for our practice? It means that your job now includes things that it may not have included. For some time, in the home setting, we were screening all patients for Zika, Ebola, and SARS. COVID-19 screening is now going to be common place for every new patient. It is also going to be common place for every patient visit. If you can’t get your nails done without getting your temperature taken, you definitely shouldn’t be in a physical therapy clinic without it. And while you are taking your patient’s temperature (or your aide is), why not also take their heart rate and blood pressure? Let’s screen for hypertension, too. Maybe even catch some early heart failure? That’s what providers do. If you walked in to see a primary care doctor and didn’t have your blood pressure taken, would you even bother going back? I wouldn’t. In the outpatient world, we are providing primary care, so let’s act like it.

It is now our primary job to ensure these patients are receiving screening for the cognitive and mental health effects of their COVID-19 experience and for the cardiovascular impairments they may be experiencing beyond the generalized weakness and difficulty with ADL. We have talked in previous posts about the side effects of ARDS, PICS, mechanical ventilation, ECMO, proning, and so many other interventions these patients may have experienced. The side effects amount and most of them are within our scope of practice to screen, evaluate, and treat. Anxiety and depression already have a bearing on participation in exercise as well as the pain experience, so when is the last time you screened for either? When is the last time you applied exercise as the treatment of either? There is plenty of evidence to back it up.

Photo by Ketut Subiyanto on

We know that the risk for clotting increases significantly (Read more here!) so screening for DVTs and PEs may become something done at every visit. That also means screening and considering the increased risk for strokes. We also need to be establishing a baseline for delirium and other cognitive factors that can change as a result of COVID-19 like we discussed here. Set the baseline and document improvement through skilled assessment over time!

Sure, sure. Taking vitals is not a skilled or billable service. But your interpretation of vitals IS a skilled procedure. This is how you determine your patient’s safety to participate in exercise, or if they might have a PE, or if they are clinically hypertension. I promise you, we are not looking for zebras amongst the horses. We are just looking at the horses. And if you don’t look, you won’t see them until they are stampeding over you.

Beyond screening, we also need to provide interventions for these impairments to the fullest of our abilities. If this care is outside of our scope, we need to be making the referrals necessary to ensure these patients receive the proper interventions from the proper providers within our interdisciplinary team. Education is a huge part of our skillset. I often say that, as instructors in PT programs, we are not just teaching physical therapists, we are educating educators. Education on any of these topics, as well as lifestyle modification interventions, are going to start taking their place front and center in our profession, so be ready.

For some of us, this may not be new. Some of us may have been doing this for some time. Medicare deems physical therapists competent to provide services like medication reconciliation and management, anticoagulation monitoring (PT/INRs) (yes, we do minor blood work), and perform diabetic teaching including the use of blood glucose assessing devices. We need to consider the ability to request labs: UAs to check for urinary tract infections, CBCs to check hemoglobin status, dopplers to check for DVTs, plain film radiographs after a fall, and ABGs when concerned about advanced COPD and oxygen use. (Of course, you better have some good reasons to back up your requests and a good relationship with the physician helps!) If you think about it, all of these things are necessary for us to provide whole-patient care and ensure our patients are safe to perform exercise. Even if Medicare didn’t deem us competent, we were educated to be.

Don’t know how to do this or where to start? Head on over to SRA Lab and take a looksee at their RehabMeasures database. Some of you may remember this as “” but that doesn’t exist anymore. The new site is packed full of screenings and tools that are validated for PT use in any patient population you can think of and for almost any diagnosis. Bonus: most of them are free!

  • Need an assessment of caregiver strain for your patient who has cancer? They’ve got that.
  • Suspect depression your geriatric patient with COPD and diabetes? They’ve got that.
  • Forgot how to quantify tone for your patient who had a stroke after COVID-19? They’ve got that.

President Dunn’s address reminded me of some of the topics in my Podcast with my home health friend Afrin where we looked back in history at how PTs have responded to pandemics and other crises. This is what primary care management looks like. This is the role we need to take on and it’s the role we were educated to fill. Who wants a soft job, anyway?

How do you provide primary care? Tell me more in the comments!

More Reads…

The Donut Hole in Primary Care PT

The occurrence of federal legislation that heavily impacts the practice of Physical Therapy typically comes from changes to the Medicare and Medicaid system. These laws don’t normally change how we practice, but moreso change how we document and bill for things. However, several bills recently introduced to Congress could significantly impact how Physical Therapists provideContinue reading “The Donut Hole in Primary Care PT”


Something went wrong. Please refresh the page and/or try again.

Follow my blog for more!

If you want to watch all of President Sharon Dunn’s address, check out the link!


Mayer, K., Engel, H., Falvey, J., Ricard, P. (2020). COVID-19: ICU to Home Transitions. [Webinar] Home Health Section of the American Physical Therapy Association. Retrieved from

Follow @DoctorBthePT on Twitter for regular updates!

Chronic Disease Part 4: Type 2 Diabetes – Part 1

Let’s start with a story…

Man on a Train

I was exiting a train on the platform at Reagan Airport when suddenly I see a man falling back onto the train as it was pulling away. His eyes were rolled back and he looked limp. My husband and I pulled him off the moving train that was starting to carry him down the platform. He was somewhat conscious, enough to get a faint mumbled medical history which included diabetes. He swore he had eaten this morning, just an apple, but he knew his blood sugar was fine. I checked him for injuries and monitored him until first responders arrived.

I passed on the history of diabetes to the first responders. Their first task was to take his blood glucose. It was in the 30s. His apple had not been enough or there had been some issue with his medications and he was tanking fast. I had some candy, so we gave him that, and they took him away in the ambulance.

Photo by Polina Tankilevitch on

I feel like Physical Therapists should be on the front line providing treatment for diabetes. Yes, I said front line, and yes, I said treatment (and I’m not alone in that!). And not just because up to 80% of the patients referred to us HAVE some type of diabetes! But, we have definitely not positioned ourselves this way. We currently treat diabetes as a comorbidity, when really it’s almost always the primary concern.

Diabetic with a broken leg? Diabetic changes to the blood vessels resulted in poor nutrient circulation to bone tissue resulting in decreased bone quality.

Diabetic with cancer? Systemic declines in immune function secondary to diabetic changes reduced the ability to fend off cancer.

Diabetic with a wound (even a surgical wound)? Healing is going to take twice as long, if not more because diabetic changes to the tissues and vessels will reduce the ability to heal. Diabetes may have even caused the wound to start with!

Diabetic with a frozen shoulder? Don’t even get me started…

So, why don’t Physical Therapists position themselves to treat diabetes? Well, it’s pretty hard to make exercise sound like a better treatment than taking a single Metformin every day… But, I’m here to give it my darndest.

Managing Type 2 Diabetes

Blood glucose monitoring. Your ability to do this may vary based on your state, but we all know the importance of blood glucose levels for exercise. If we don’t time our sessions properly, we end up with a patient passing out on us. If we do time them properly, we can actually (over time) decrease or eliminate the need for medication to manage blood glucose. Let’s talk about the logistics of this:

  1. To clear up the risk analysis: If your patient is already diabetic, they already have a physician’s order to check their blood glucose daily. If you ask them to or assist them in doing this prior to your session or during your session, you are in full compliance with this order. If you need to do this for your patient because they are unable, you are still in full compliance with this order. If your patient’s blood glucose is so low that they are unable to measure their own blood glucose, are you going to sit there wondering if it’s ok while they fade away? No, of course not. You should probably be calling 911 at that point, but take their blood glucose. (Side note: please wear gloves.) Diabetic teaching is well within our scope of practice. So is diabetic intervention (aka exercise). PTs can even become certified diabetic educators.
  2. You cannot administer insulin if your patient’s blood glucose is too high unless you are trained to use the devices to do so and there is an order in place (if your patient is diabetic, there is an order in place, but you have to know how much, i.e. sliding scales and all that). You should be calling the physician or nurse case manager for instruction if your patient cannot self-administer. You can, on the opposite end of the spectrum, give your patient food. You should have fast-acting sugars available in your clinic: juice, candy, applesauce… Even in outpatient clinics, I’ve given juice when I noticed the signs of hypoglycemia.
  3. You, yes YOU, a rehab clinician, can educate patients on diet, how to use a glucometer, and how to use a sliding scale. It is within the scope of practice of a physical therapist to educate on medications as the primary case manager under Medicare guidelines. If you can do an OASIS, you can teach meds. As a matter of fact, it is EXPECTED that you complete the meds teaching to the best of your ability and consult nursing for the rest. Sliding scales are provided for you by the primary care physician or endocrinologist, so you just explain how to use them. If you aren’t sure, check out some online training courses to get more information.
Photo by Artem Podrez on

Not My Patient

I made a home visit to evaluate a very kind woman who did not want my help. She wasn’t rude, she was just straightforward. As her doctor did order PT for falls, I talked her into letting me do a walk around the house with her.

It wasn’t her house, she told me. She was just staying with family for a while until she felt better. We walked through a few rooms and saw a few different people. It wasn’t their house either, she explained. Her family takes in people who need some help until they can get back home. She was walking fine without a device, albeit a bit slow over the changing carpets in this piece-meal home.

We passed by a bedroom where her sister-in-law was shaking a man lying in bed. The woman was audibly yelling at the man who was only somewhat mumbling back to her. I sat back down at the dining table with my patient who clearly told me she was fine. And then I hear the words from the other room…

“530? What does that mean? What’s his sugar supposed to be?”

I smiled at my patient and said, “if you don’t want me to come to see you, that’s fine with me. That man right there is in trouble. Would you mind if I helped him?” She smiled and said, “of course, honey, he’s been real sick.”

I ran to the room and did a recheck on the glucose. The 530 was just the most recent on the glucometer history. The actual was 615. He was losing consciousness when I called 911. The family gave me a first name and age but I had no other medical information. The paramedics were quick to arrive and stretchered him quickly to the ambulance.

Photo by Polina Tankilevitch on

What ARE the signs of hypoglycemia?

I’m so glad you asked!

  1. Arrhythmia
  2. Fatigue
  3. Palor
  4. Sweating
  5. Anxiety/mood changes
  6. Confusion
  7. Lightheadedness/headache
  8. Shaking
  9. Unsteadiness
  10. Anxiety

And one list is not complete without the other…

What are the signs of hyperglycemia?

  1. Fatigue
  2. Weakness
  3. Confusion
  4. Nausea/vomiting
  5. Shortness of breath
  6. Dry mouth/fruity breath
  7. Urinary frequency
  8. Headache
  9. Blurry vision

Now look at those two lists… lots of similarities there… so it may be difficult to actually tell if your patient is hyper or hypoglycemic. This is why you will need to check their blood glucose.

Photo by Nataliya Vaitkevich on

The Need to Know

Just like with pulse oximetry for patients with respiratory conditions, blood glucose in people with diabetes is something I NEED to know. I need to know what it is before exercise, what the trends are, and what it is first thing in the morning. That’s how I know if the diabetes is well-managed or not and determines how and when I prescribe exercise.

What are safe parameters for blood glucose?

I thought you’d never ask! Here’s the meat and potatoes. Let’s put these numbers in order from least to most and make a scale. Remember, these numbers assume the person already has a diagnosis of type 2 diabetes.

Too Low

<50 mg/dL
call physician/911 based on symptoms,
give sugar

Too Low for Exercise

<70 mg/dL,
give sugar

Ideal Range for Exercise

100 – 250mg/dL

Too High for Exercise

>250 mg/dL call physician, risk of ketoacidosis

Too High

>350 mg/dL call physician/911 based on symptoms

If a patient with diabetes is participating in an exercise class or performing exercise in long bouts (longer than 60 minutes) blood glucose should be checked every 30 minutes to ensure ongoing safety to reduce the risk of ketoacidosis or hypoglycemia. Ketoacidosis is when there are too many ketones in the body. For diabetic people, this can be life-threatening. But, that’s a whole other condition, so we will talk about that later. Just know that it is a medical emergency and refer to my friend above who wasn’t my patient.

Effects of exercise (which are many!) on blood glucose only last 24 hours, so some type of exercise should be performed EVERY day for long-term stabilization and management. And, as I usually make the statements about properly prescribed exercise, that all applies here, too. Set a baseline exercise tolerance or aerobic capacity, measure vitals, calculate heart rates, and exercise to the proper ranges. Not only will this help manage blood-glucose long-term, but it will help reduce pain associated with peripheral vascular changes due to diabetes, too.

Don’t Forget Diet

Nutritional counseling is well within our scope of practice as rehab providers, especially if our patients are diabetic. It isn’t even safe for our patients to exercise without knowing the basics of how energy input and energy output affect their health status.

Photo by Andres Ayrton on

Don’t be shocked if your patient doesn’t know where sugar comes from, what carbs are, or if bread is a protein or not (very serious, I had that exact conversation once). Some people take it upon themselves to know a lot about their health and what they can do to manage it, but many people don’t. Their health is something that happens to them, not something they actively participate in. So, it will take a lot of counseling to get their energy inputs and outputs back on track.

Don’t forget to call on your handy dandy dietician, too. Diabetes takes a team. Hopefully, you are on that team and can help the patient balance those energy inputs and outputs and keep them safe while you do it.

Keep in mind that the more comorbidities your patient has, the harder it will be to control their diabetes. Many medications and other conditions impact blood glucose and just throw the whole thing off! Goodness, so much to cover and we haven’t even gotten to the feet yet! I guess the diabetic foot will have to be another post. Keep checking back for Part 2 and I’ll keep your brain busy! I’m definitely not done yet!

How often do you teach patients how to use their glucometer? Tell me about it in the comments!

Get new content delivered directly to your inbox.

More Reads…

Follow @DoctorBthePT on Twitter for regular updates!


Liu, Jx., Zhu, L., Li, Pj. et al. Effectiveness of high-intensity interval training on glycemic control and cardiorespiratory fitness in patients with type 2 diabetes: a systematic review and meta-analysis. Aging Clin Exp Res 31, 575–593 (2019).

Magalhães, J.P., Melo, X., Correia, I.R. et al. Effects of combined training with different intensities on vascular health in patients with type 2 diabetes: a 1-year randomized controlled trial. Cardiovasc Diabetol 18, 34 (2019).

Marcie Harris-Hayes, Mario Schootman, Jeffrey C. Schootman, and Mary K. Hastings. The Role of Physical Therapists in Fighting the Type 2 Diabetes Epidemic. Journal of Orthopaedic & Sports Physical Therapy 2020 50:1, 5-16

Mayo Clinic. (2020, May 13). Hypoglycemia.

Mayo Clinic. (2020, June 27). Hyperglycemia.

Centers for Disease Control and Preventions. (2021, April 28). Diabetes: Manage Blood Sugar.

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Airway Clearance Techniques

Airway Clearance Techniques (ACTs) are the best practice for patients who are in acute exacerbation, sub-acute exacerbation or are stable with obstructive lung conditions.
Long-term management of obstructive lung disorders including cystic fibrosis, COPD, bronchiectasis, and chronic bronchitis, and those with impaired cough including ALS, SCI, and post lung transplant should include instruction in ACTs.

Pulmonary Hygiene takes a team – reinforce the regular performance of ACTs!

I have a special treat for you!

I created this a while back. All you MDTs out there will love it. This is a force progression (backed with evidence!) for applying, combining, and progressing airway clearance techniques. It starts out with the patient providing their own forces from the inside and outside, then adds the external forces you can apply as a part of your airway clearance techniques.

Brockway, K. (2017) Pulmonary hygiene toolbox – force progression tips
(Original content)

Tips for airway clearance techniques:

  • These are considered AGPs (Aerosol generating procedures)! Therefore, they require full PPE and an N95 mask per the CDC guidelines when performing with a patient with known or suspected COVID-19 (or any other viral infection of the lungs).
  • Always consider changing positions to utilize postural drainage positions to encourage increased secretion mobility.
  • When implementing oscillatory devices, keep in mind that not all oscillatory devices can be inverted or turned sideways and continue to function (such as the Aerobika). However, some can do this easily (like the Acapella).
  • Have tissues ready! My friends in ICU tend to use a cup. Secretion color and consistency matter and can tell you really important things!

Don’t forget about other tools in your toolbox!

  • Increase water intake: This thins secretions so they are more mobile.
  • Increase overall mobility: increasing mobility means increased respiratory rate and depth which naturally mobilizes secretions.
  • Change positions frequently: utilizing postural drainage positions or just changing positions frequently throughout the day reduces consolidation.
  • Utilize Mucolytics: for very thick secretions and/or patients who are not mobile to improve secretion consistency for better mobilization and expulsion.

So that’s just the intro! Come back often to find all kinds of great techniques and information to update your skills and get you ready to practice in the cardiopulmonary setting!

More from the Pulmonary Rehab Toolbox…

Blow Out the Candles…

If there is any treatment that I feel like gets used in a cookie-cutter fashion, it’s pursed-lip breathing. As much as I hate seeing this technique used for every single patient that has shortness of breath, it does have clinical usefulness. So let’s talk about how to implement pursed-lip breathing properly based on patient presentationContinue reading “Blow Out the Candles…”

Postural Drainage

We’ve all seen that dreaded picture in our textbooks… All the human figures laying in so many different positions with pillows and tables tilted all over… and I very clearly remember thinking, “How on earth am I supposed to remember all of those?” Well, good news. You really don’t have to. It’s great if youContinue reading “Postural Drainage”

The Duet Device

Have you seen an Acapella Duet before? This is another one of those things I wish I could hand out to maybe half of my patients. A Duet device is a special kind of Positive Expiratory Pressure (PEP) that provides resistive oscillatory pressure to exhalation which promotes increased lung volumes due to re-inflation of collapsedContinue reading “The Duet Device”


Something went wrong. Please refresh the page and/or try again.

Follow @DoctorBthePT on Twitter for regular updates!

Pulse Oximetry and O2 Saturation

This may seem simple… but it is my constant battle: valuable but so difficult.

This is one simple vitals measurement with one tiny tool. There can’t be that much to it…

Let’s go for a ride down the river.

The first day at your new job, there are lots of jobs for your team to do, but there just aren’t enough people showing up for the jobs. If these people don’t show up, you will still all get in your boats and go down the river to work, but there just won’t be enough people to get all the jobs done. You will work your butt off and feel exhausted, but the work just won’t get done.

The second day, all your team members finally showed up, but the boat company gave you fewer boats based on yesterday’s attendance. So now you have all the people to do the work, but you can’t get everyone down the river to work to do the jobs. Again, you will work so hard, be exhausted, and the jobs will not get done.

The third day, there is a storm. There are trees fallen across the river. You have your boats and people this time, but it is really difficult to get down the river to work because there are so many tress in the way and the path is very narrow. So the people who get there will work really hard, feel exhausted, and the jobs still won’t get done.

The fourth day, a new company moves in and builds a dam upstream. They will only let so much water flow through the dam and its just not enough to float your boats down the river, so you have to walk to work. You’ll get there, slowly, but you’ll lose a lot of time and you’ll be exhausted and the work won’t get done.

This is how our patients feel in different states of oxygen deficiency.

People = Oxygen Molecules
Boats = Hemoglobin
Trees = DVTs/atherosclerotic plaques/arterial calcification
The River = Cardiac Output

There is a whole set of considerations to using pulse oximetry. SpO2 only measures the saturation of oxygen in hemoglobin. But what if there isn’t enough hemoglobin? You can have them 100% saturated but still have a very breathless patient who need critical intervention (a transfusion!). And what if there isn’t enough cardiac output, literally not enough blood leaving the heart (aka Ejection Fraction) to go to the body? Now your patient doesn’t even have enough breath to walk to the bathroom and your oximeter is reading 100%. What if you have enough output, but the vessels are obstructed due to PVD or PAD or a DVT? Pulse oximeter still reads 100%, if you can get a reading at all.

The story of the people and their boats is how I explain each of these deficient states to my patients depending on what state they are in.


Yep. That’s how I feel about pulse oximetry. I NEED to know when my patient is desaturating. I need to know how much. I also need to know if they are too saturated! And, in the home environment, or in the gym at my SNF, I have pulse oximetry to give me those answers. The unfortunate thing about pulse oximetry is how unreliable it can be and how difficult it can be to use. But, like I said, I NEED it!

If you are regularly using a fingertip pulse oximeter, there are a more than a few things you need to know:

  • You need to simultaneously palpate or auscultate the patient’s heart rate/pulse rate during use. If the heart rate doesn’t at least somewhat match from manual palpation to the device reading, you cannot trust the oximetry reading.
    • These devices require a regular and relatively strong heart rate to provide a proper reading.
    • Most oximeters have a heart rhythm bar that goes up and down with each beat. If that bar is not going up and down in a regular fashion, the oximetry number is not correct.
  • If your patient has any cardiovascular comorbidities, odds of a pulse oximeter working are reduced. You may be thinking, “Well shoot, Doctor B, that’s who I need to be using this with.” And you’d be right.
    • Does your patient have A-Fib? Definitely won’t work. (see above)
    • Do they have PVD? Almost definitely won’t work. (see above)
    • Do they have peripheral neuropathy? Probably won’t work.
    • Do they have Raynaud’s Phenomenon? Probably won’t work.
    • Do they have essential tremor? Definitely won’t work.
  • If your patient has no fingers or toes, I don’t even know what else to tell you. There are different types of pulse oximeters that can be taped to different body parts like ears, feet, hands, arms, wherever you can get good contact. They are regularly used in NICU settings. But, I don’t carry one of those in my bag and my SNF doesn’t have one. So…
    • Unfortunately, these other devices come with their own flaws. Performing isometric contractions of the muscles where they are located can drain the local oxygen supply and show falsely depleted oxygen saturation. (Death gripping a walker handle will impair fingertip oximeter readings.)
    • They are also more prone to interference from body movement if you have to perform any other type of activity with the body part it is attached to.

So, what the heck do I do with this thing?

Correlate clinically.

Your pulse oximeter shows desaturation to 84% but your patient is happily talking and exercising with you without shortness of breath and they have no pulmonary pathology. Obviously a false reading.

However, your patient is sweating, panting, and slightly dusky around their mouth while walking with you. You know they recently had COVID-19. Your pulse oximeter says 96%. Obviously a false reading.

If things aren’t making sense, pick a different finger and make sure that finger is warm before putting the oximeter on it. If that doesn’t work, change your batteries.

That’s Troubleshooting 101, 102, 103, 401, and 700. Make sense?

Hint = SpO2 is oxygen saturation measured with an oximeter. PaO2 is the partial pressure of oxygen in the blood measured with an ABG.

image credit

So what’s normal?

Even debilitated patients who probably have a lower ejection fraction shouldn’t significantly desaturate with normal activity unless they have severe comorbidities, like end-stage COPD. If they are, they need supplemental oxygen to perform these tasks. A normal decrease in saturation with activity is 1-2% even if someone has been immobilized. SpO2 should be around 97-99% in healthy individuals.

However, if your patient desaturates more than 4%, or desaturates to less than 90% SpO2, with activity, this is a problem (unless they are a CO2 Retainer). If this happens, you should hopefully see some compensations in heart rate or blood pressure, or both, and it should recover with rest.

What if SpO2 doesn’t recover with rest?

If your patient’s SpO2 is dropping with basic household mobility, your patient is struggling to function, and their vitals show hypoxia, you either need to get them supplemental oxygen, or you need to titrate the supplemental oxygen they already have.

WHOA!!! Hold up, wait a minute!

I know, I know. You are thinking, “Oxygen is a drug, I can’t titrate it without a doctor’s order!” Yes, you are absolutely right. But are you going to let your patient go in to acute respiratory distress in the meantime? I think not.

While you are helping your patient recover from their desaturation with rest, breathing, and increased O2, get the doc (or their nurse) on the phone, let them know what you found and what you did. Ask them for some “titrate to” orders to help you out so you don’t have this problem anymore. I’m sure they will be happy to oblige you. Team work makes the dream work.

So what about COVID-19?

In the rush to open critical beds and move people out of the hospital as quickly as possible, rehab and nursing providers may not get the full opportunity to assess a patient’s response to activity, specifically their oxygen response. When you start seeing these patients in the post-acute settings, like home care, inpatient rehab, sub-acute rehab, or skilled nursing settings, you may find they weren’t quite ready to be off supplemental oxygen all together just yet. It is very possible your patients still may need supplemental oxygen with activity, even if they are well saturated at rest.

How do you know when a patient is orthostatic or just deconditioned as opposed to needing supplemental oxygen to prevent hypoxia with activity? The symptoms can be similar: shortness of breath, increased respiratory rate, fatigue, lightheadedness. So how do you know? Here’s how:

Take baseline vitals at rest (like really rest) in supine (HR/PR, BP, O2, RR)
Sit up and take another set of vitals
Perform an ADL or UE activity from seated and take another set of vitals
Stand up and take another set of vitals
Walk and take another set of vitals

If blood pressure drops, heart rate rises, and oxygen stays the same on the BOLD lines, you have orthostasis.
If blood pressure and heart rate elevate, and oxygen drops on the ITALICIZED lines, you have activity-induced hypoxia.

With orthostasis, blood pressure changes happen in response to changes in position with gravity. Blood pressure drops and the heart attempts to compensate by rising, but O2 saturation should stay the same, even in a deconditioned person. We will talk more details on this in another post.

With activity-induced hypoxia, blood pressure elevates and heart rate elevates in response to low oxygen levels (the body is trying to get more oxygen-rich blood out to the tissues to complete whatever work needs to be done), but the diffusion of oxygen across the alveolar membrane isn’t happening at a rate that can match the demand (problem with V/Q matching) due to the alveolar destruction caused by COVID-19 (or any other pulmonary pathology). This patient needs some supplemental oxygen. They could also benefit from some hyperinflation techniques if they have recently been ventilated, experienced pneumothorax, or any other condition that would result in collapsed alveolar clusters (aka restrictive conditions).

I get pretty high on my vitals soap box sometimes, but this is why. These numbers are where your decision making NEEDS to come from. You can’t base your treatment on how the patient looks or how they say they feel. You have to see the numbers for yourself and know the numbers are correct.

What’s next?

Start exercising! Left ventricular remodeling is important to get cardiac output up and helps to improve ejection fraction over time. Alternating intervals helps to alternate lung volumes which helps with reinflation of collapsed segments. These happen with exercise!

In the acute and immediate post-acute phase, you should be targeting a 5 on the Borg RPD scale (moderate) or whatever corresponds to moderate breathlessness on the scale you use. You don’t really want to go higher than that because of the severe pathology this patient is still fighting.

In the sub-acute and ongoing settings, start working them harder. If they begin to be more limited by deconditioning than breathlessness, switch to a Borg or Borg Category Ratio scale instead and target 7-8/10. Use heart rate calculations if you can (Call up your old college buddies, Tanaka and Karvonen) to be more precise in your prescription with 70-80% HRmax. Make sure you are utilized standardized measures to establish baseline function and demonstrate improvements over time!

Hey, Doctor B, I think you got a little carried away here…

Yea, probably. Thanks for sticking with me.

I will tell you that I’ve had all of these patients in the home and SNF settings. I’ve ordered supplemental oxygen at a home PT eval. I’ve explained a 15% ejection fraction and why this patient needed to wear oxygen even though his SpO2 was 97%. I’ve called the doc and requested a CBC to check hemoglobin levels (and I’ve been right). I’ve titrated oxygen for recovery and requested “titrate to” orders more times than I can count. I’ve read ABGs and found new CO2 retainers. If I’ve encountered it, you will, too. So I want you to be ready and understand what you need and why you need it.

That was a lot. If you want to know more, ask me in the comments!

More from the Pulmonary Rehab Toolbox…


I spent some really great times as an educator in a heart and lung transplant program at a large hospital system. Specifically, I was a therapy educator. I taught PTs, PTAs, OTs, COTAs, and SLPs what they needed to know to safely provide rehab to patient after heart and lung transplants. I saw so manyContinue reading “FEV1”


HFNO stands for High Flow Nasal Oxygen. This is something that was used frequently in patients who were desaturating quickly with symptoms of COVID-19. It has the ability, through the use of several different devices or setups, to deliver very high concentrations of supplemental oxygen to patients with advanced pulmonary diseases or conditions. In theContinue reading “HFNO”


Something went wrong. Please refresh the page and/or try again.

Follow @DoctorBthePT on Twitter for regular updates!

image credit


Hillegass, E. (2020). Vital Signs, oxygen, & exercise prescription: How are these impacted by COVID-19? PACER Project. Cardiovascular and Pulmonary sections of the APTA. Retrieved from

%d bloggers like this: