BY Claudia Gary

The origins of physical therapy can be traced to the beginnings of medical science. PT uses physical intervention to restore mobility and independence or to prevent loss of mobility before it can occur. Although PT can involve manual therapy, its full effect usually requires active participation by the patient. Such activity may at first be difficult—especially for a patient who has suffered serious injury, stroke, or amputation, or who is recovering from a joint replacement surgery. Ultimately, though, the activity itself becomes the basis for an enhanced quality of life, including independence and mental health.

PT also helps avoid dependence on pain medication, an especially important focus in the face of the current opioid crisis.

Obioma “Oby” Ogbuawa is a Board-Certified Orthopedic Specialist who works with patients at the Washington, D.C., VA Medical Center. Many of her patients are Vietnam War veterans.

When asked about the most prevalent problems she sees among Vietnam veterans, Ogbuawa named low back pain, neck pain, and knee pain as “probably the top three.” She also treats amputees and patients who have had knee or hip replacements, and gets referrals for patients with MS or who have residual weakness from strokes.

“We’re seeing a lot of patients now who are in their late sixties,” she said, “So a lot of them have had joint replacements. I’m seeing them post surgery, post hip replacement or knee replacement.”

One feature of working at the VA is the potential for collaboration with other specialists. “It’s easier here because we have everything under one roof,” Ogbuawa remarked. “I can make a phone call and have a psychologist come down. If they see something, we can get it right. Or if I see a wound on someone, I can have a doctor come in and take a look. Whereas on the outside, I would have to send someone to an ER or urgent care, and I may not have that same follow-up with them.”

This can sometimes produce results that go beyond what patients have experienced elsewhere. “We have a therapist who has a neuro specialty and is working with patients who have had strokes. She is able to get them in and work through things where sometimes outside insurance limits their ability to go to multiple sessions. She’s been able to get people who would be wheelchair-bound to walk. I would say the same thing about our amputation program. I’ve seen therapists on the outside who have decided some patients won’t be able to be ambulatory. We’ve gotten them in, and they have been able to walk with an assistive device such as a single crutch or a single cane.”

She also sees friendly collaboration between veterans. “We started a total joint replacement group about four years ago, where veterans who had surgery would come and do their rehab together. There’s a real sense of peer support among them. They push each other to work harder. I’ve seen a lot of people develop enduring friendships here based on what they’ve been able to go through together.”

In response to the opioid crisis, the VA has started pain clinics, which also rely on combining specialties. “We started ours about three years ago; it’s a collaboration between a physical therapist, neurologist, social worker, and a psychiatrist. They work together to find the best treatment plan to help reduce pain,” she said. “I think that’s been very helpful. It’s one of the first places people now like to go to in the clinic, because they’re using things such as acupuncture with exercise and other modalities to give patients a better understanding of their pain and how to self-manage.

“In our department we work very closely with the physiatrist. Sometimes manual therapy is working a little bit, but there are ways a trigger point injection may help, and it works better in combination.” Other options available in the pain clinic include massage therapy and yoga, as well as “a physical therapist who helps to construct an exercise program and get an overview.”

Pain medication may occasionally restrict PT’s ability to help, she said. “There are some times when a patient initially might be unable to work, and we say maybe they’ve had too much pain medication. So we talk with the doctors, and they can help to titre that down a little bit so we can get some treatment done. And sometimes a trigger point injection is needed, or we refer them to orthopedics so they can have a shot in the knee or other adjunct therapies.”

And then there’s the essential collaboration between the patient and the physical therapist. Do patients generally maintain exercise programs therapists design and recommend for them?

“It really depends,” Ogbuawa said. “I think the biggest issue is whether or not patients have the self-motivation to keep going. It varies from person to person. If exercises are helping them, they are compliant to the utmost. It’s just about finding something that helps them immediately.”

Asked whether there was a difference in buy-in between older and younger veterans, Ogbuawa said it seems to be a matter of how much time they have. “A lot of the younger veterans are working, going to school, and trying to come to therapy. The older veterans have been through that, and they are now slightly better in exercise or coming to therapy more often. It could just be the fact that they now have more time. Some of our younger veterans are trying to balance so much.”

“I had one veteran who, in the middle of one session, started crying,” Ogbuawa said. “I was very shocked—I didn’t know if I had done something wrong—but it turned out that dealing with the pain had helped her deal with something else she hadn’t addressed in the past. I was able to set her up with mental health services in order to get her evaluated. She stopped by a couple of months later to say hi, and said she was still going to mental health, and she was glad that I had referred her. So sometimes, even though you think you’re just treating a body part, other things can arise. That’s a benefit of being here: We have that direct referral, and we can seek out a psychologist.”

In another case, she said, “One of my amputees was in a wheelchair for about two months and wasn’t progressing, even though he had all the potential in the world. We talked about a couple of things that he had gone through in his life, and I said, ‘We have mental health services here, and I know it’s hard for you to get here’—because he hadn’t done any driving training since he’d had his amputation. So I contacted psychology services, and the psychologist came down and participated in physical therapy. We did a couple of co-treatment sessions together.

“From her just being here with him, in a short time we saw his attitude completely change. He really wanted to be able to drive. We have a driver’s rehab program with our occupational therapy, and we were able to coordinate his treatment sessions so that he would have PT, then he would go to his mental health appointment, and then to his driver rehab. Now he doesn’t have to rely on his wife to drive him to the Medical Center or to Home Depot or other places; he can get up and go on his own. And he loves it.”

“One of the ‘big pushes’ in physical therapy is education in women’s health,” Ogbuawa said. “This is on the outside and now coming into the VA. Five years ago, I would treat maybe one new female veteran a month. Now I probably have six or seven on my caseload. At our VA we have opened up a women’s health clinic, and they have all the physicians there, and we are doing a one-day-a-month clinic in order to educate on pelvic floor services for incontinence or urgency.

“A lot of times, these issues are masked as lower back pain. Women often have issues after childbirth, and they kind of keep it to themselves, and they think, ‘Oh, this is normal.’ But we let them know that these are also things we can help with.”

When asked whether physicians and other practitioners fully understand how much physical therapy can achieve, Ogbuawa replied: “It’s important to work on education. Sometimes physicians who work in hospitals have a different view of what a physical therapist does versus a physician who works in the orthopedic section. Other times you find that the physicians who understand physical therapy best are those who have had physical therapy done for them. We do a lot of education inside the hospital, and we talk to orthopedic surgeons so they’ll understand what services we provide.”

Other practitioners also have benefited from working with physical therapists. “Now we have audiologists within the
VA. We met with them in November or
December to educate them on vestibular rehab, because they treat patients who have vestibular issues like dizziness and balance issues. Now they are directly referring patients to PT if they can’t make improvements with them to work on positional changes, as well as helping patients who have issues with dizziness.”

Even patients who may not have an immediate need for physical therapy can benefit from learning about it, or even from one or two PT sessions as a preventive measure, Ogbuawa said. “Most of the research shows that decline of strength starts to happen within the third decade, and I think a lot of people could benefit from education on just back exercises and strengthening the lower extremities. It’s just to decrease, as we age, the risk of falls, fractures, and problems with posture. I can’t tell you how many people have been referred to me with neck pain because they’re always looking at their cell phones.

“Also, outside the VA, I’m seeing kids who are complaining about low back pain, and it’s because their backpacks are so heavy. They’re having to carry all these books, and their spines are not strong enough. Even here, some of the veterans don’t want to use a wheelable book bag because they find that it slows them down. So they throw it on their back—a pack with their laptops and the book bag and their workbooks—and they are complaining of back and neck pain.

“I’ve had veterans who work in IT, and they are complaining of neck pain, and the question I ask them is, ‘How many computer screens do you have?’ They say two or three. A lot of people these days use two or three screens, and that causes them to have a lot of neck pain. So sometimes I just say, ‘Why don’t you set up your screens in different areas so that you’re not just twisting your neck, but you have to move your chair.’ And they find that they already have 50 percent improvement. So I don’t think there’s anyone who couldn’t benefit from PT.”

Vietnam veterans are remarkable for their camaraderie, Ogbuawa said. “I’ve had instances of people in therapy who served with each other fifty years ago. They meet, and they haven’t seen each other since they served, and they recognize each other. It’s always fun when you see that connection happen within the therapy department.”