Why Physical Therapists Must Monitor and Adapt Care for Medication Influences

Understanding patient medications is crucial for physical therapists (PTs), especially given the increasing prevalence of polypharmacy and the rising need for chronic disease management among older adults. Polypharmacy, commonly defined as the use of five or more medications, has become more widespread with the aging American population. Between 1988 and 2010, the proportion of adults aged 65 and older taking five or more medications tripled from 12.8% to 39.0%¹ . This trend underscores the importance for PTs to be vigilant about the medications their patients are taking, as these can significantly influence therapy outcomes and the need for personalized care adjustments.

Many medications necessitate modifications in exercise interventions. For instance, beta-blockers, commonly prescribed for cardiovascular conditions, reduce heart rate and can blunt the typical heart rate response to exercise. In such cases, relying solely on heart rate to monitor exercise intensity may be ineffective. Instead, PTs can utilize the Rating of Perceived Exertion (RPE) scale, which allows patients to subjectively assess their exercise intensity, ensuring safety and effectiveness without depending on inappropriate heart rate measurements.

By integrating medication awareness into clinical practice, PTs can tailor interventions to accommodate the effects of various drugs, thereby enhancing patient safety and optimizing therapeutic outcomes.

Understanding the Peaks and Valleys in Medication Use

Physical therapists should consider the concept of 'peaks' and 'valleys' in medication use when planning treatment goals. The peak of a medication's effect is when it is most effective at reducing a patient’s problematic symptoms, while the valley represents the point where the medication is least effective and is beginning to exit the system. Understanding these phases is essential for creating effective treatment plans that align with a patient’s functional abilities and therapeutic needs.

Each medication will have its own specific timeline for reaching peak effectiveness and declining toward the valley phase. To understand these timelines, PTs should familiarize themselves with the principles of pharmacokinetics and pharmacodynamics. Pharmacokinetics refers to how a drug moves through the body, including absorption, distribution, metabolism, and excretion. Pharmacodynamics describes how the drug affects the body, including its mechanism of action, therapeutic effects, and side effects. PTs do not need to memorize this information for every medication, as it is impossible given the vast number of drugs available. However, they can look up this information with a quick internet search (more details about this later). This knowledge enables PTs to roughly estimate when a drug will be most effective or least effective to modify their interventions and goals appropriately.

Again, this process requires both preparation and communication with other healthcare providers, such as physicians and pharmacists, to clarify medication schedules and effects. Timing interventions based on medication phases can be critical for maximizing functional gains. For example, a patient with significant spasticity following a stroke who is using baclofen to control the symptom may have varied therapy goals depending on their medication cycle. If the objective is to assess fall risk or determine baseline function, scheduling the session during the valley phase, when the baclofen's effects are wearing off, can provide a clearer view of the patient’s true capabilities. This approach helps identify challenges that might otherwise be masked by medication effects.

Conversely, when focusing on skill acquisition or functional gains, such as gait training to achieve a goal of walking 200 feet, working more toward the medication’s peak effect may be more beneficial. During this phase, the reduction in spasticity from baclofen can allow the patient to move more freely and focus on building strength, endurance, and motor control without excessive physical limitations.

PTs should also collaborate with the patient’s healthcare team to track medication schedules and adjust therapy sessions accordingly. Documenting patient responses during both peak and valley phases can inform ongoing care adjustments and help set realistic, patient-centered goals. Aligning treatment sessions with the peaks and valleys of medication efficacy, PTs can design more effective, individualized care plans that accurately reflect patient capabilities and therapeutic needs.

Medication Considerations Across PT Settings

Medication usage will vary depending on the physical therapy setting, as patient presentations and care priorities differ across environments such as acute care, outpatient orthopedics, neurorehabilitation, pediatrics, and geriatrics. For example, in acute care, common medications may include anticoagulants (e.g., heparin) for thrombosis prevention and pain management medications such as opioids. In outpatient settings, non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants are often more prevalent for managing musculoskeletal pain.

Despite these differences, there is significant overlap in medications across settings. For instance, beta-blockers and statins may be seen in both acute and outpatient settings for cardiovascular management. PTs need to remain mindful of how medications influence therapy outcomes, regardless of the setting.

Familiarity with common medications in each setting helps PTs anticipate potential side effects and adjust treatment plans accordingly. Additionally, collaboration with the healthcare team ensures that medications are factored into clinical decision-making for optimal patient care.

How to Stay Aware of Patient Medications

The following tips are informed by my formal Doctor of Physical Therapy (DPT) education and have proven extremely useful during my early clinical experiences:

1. Learn Common Drug Class Suffixes: Becoming familiar with common suffixes for drug classes can greatly assist PTs when reviewing medication charts filled with unfamiliar drug names. For example, medications ending in '-olol' are typically beta-blockers, which often share side effects like reduced heart rate and fatigue. Recognizing these patterns can help PTs anticipate side effects and adjust treatment plans more efficiently.

2. Monitor Vitals Regularly: Consistently checking vitals is a simple yet often overlooked task in clinical practice. Monitoring how a patient’s vitals respond to exercise provides valuable information about medication’s effects. For instance, a patient on vasodilators for hypertension may experience orthostatic hypotension, leading to dizziness or lightheadedness during position changes. Being aware of this can prompt PTs to modify interventions to ensure patient safety.

3. Ask About Supplements and OTC Medications: Patients often take supplements and over-the-counter medications that can influence therapy outcomes. For example, high doses of fish oil can increase bleeding risk, which may be important when working on balance or fall prevention. If a patient’s presentation seems unclear, reviewing all medications and supplements can be key in solving the clinical puzzle.

When to Refer Back to a Physician

Physical therapists play a critical role in recognizing when a patient’s medications may be under- or over-treating their condition. While PTs can educate patients on what their prescriptions are for and how to follow the prescribed dosing schedule, they do not have the authority or training to modify or discontinue medications. However, PTs often see patients more frequently than other healthcare providers, making them well-positioned to identify potential issues.

Signs of under-treatment may include persistent symptoms despite consistent medication use, such as unresolved pain, swelling, muscle tightness, etc. Interestingly, some signs of under- and over-treatment can overlap, such as dizziness or fatigue, making it even more crucial for PTs to be well-prepared. Proper preparation enables PTs to better anticipate medication effects and understand what symptoms to monitor. Over-treatment, on the other hand, could present as excessive sedation, dizziness, abnormal fatigue, or a significant drop in blood pressure. PTs should remain vigilant during sessions by thoroughly reviewing patient medications, being aware of common side effects, and directly asking patients how they feel their medications are working. Asking patients directly for other symptoms they may be experiencing is important because some issues can be overlooked during an evaluation or treatment session as they may not be readily apparent to the clinician

If a PT suspects a medication is not effectively managing symptoms or causing adverse effects, it is their responsibility to refer the patient back to their physician. This can involve suggesting the patient consult their provider directly or, when appropriate, contacting the provider personally to share observations and concerns. When a PT contacts a primary care physician directly, it can give more weight to the patient's complaints and may facilitate faster follow-up care, ensuring the patient's concerns are addressed promptly. This can involve suggesting the patient consult their provider directly or, when appropriate, contacting the provider personally to share observations and concerns.

Helpful Resources for Medication Information

Two highly reliable resources for checking medication use, side effects, and interactions include:

1. Medscape Drug Interaction Checker: Medscape offers an advanced and detailed database for checking drug interactions, side effects, and contraindications. It allows PTs to input multiple medications simultaneously and receive comprehensive interaction data. Interaction severity is categorized into mild, moderate, and severe risks, with thorough clinical explanations for each result. Medscape also provides information on pharmacokinetics, mechanisms of action, and guidance on clinical management, equipping PTs with essential insights for safe and effective treatment planning.

2. Drugs.com Interaction Checker: This tool provides a comprehensive and user-friendly database for checking drug interactions, understanding potential side effects, and learning about medication purposes. It uses a clear rating scale indicating the severity of interactions: major, moderate, and minor. Each interaction result includes detailed explanations of clinical significance and potential patient impacts, making it a helpful resource for PTs aiming to ensure patient safety.

These tools help PTs stay informed about medications and make educated decisions when planning treatment to ensure patient safety.

Be Thorough and Keep Providing Excellent Care!

Physical therapists play a vital role in ensuring patient safety and optimizing outcomes through vigilant monitoring of medication influences. By recognizing signs of under- and over-treatment, understanding the timing of medication peaks and valleys, and maintaining open communication with healthcare teams, PTs can better tailor care plans to meet patient needs and keep them safe during exercise. Staying informed about common medications and their effects empowers PTs to make evidence-based decisions that enhance patient progress and overall well-being. Ultimately, incorporating medication considerations into PT practice leads to safer, more effective, and individualized patient care.

References

1. Qato, D. M., Wilder, J., Schumm, L. P., Gillet, V., & Alexander, G. C. (2016). Changes in prescription and over-the-counter medication use among older adults in the United States, 2005-2011. The Journals of Gerontology: Series A, 70(8), 989-995. https://doi.org/10.1093/gerona/glv006

Disclaimer:

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.