Emory University | Woodruff Health Sciences Center
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New Help for HIV

A PT pioneer, an HIV clinic, and a way out of chronic pain

By Dana Goldman

Story Photo

Assistant Professor Sara Pullen works with a patient at the Ponce de Leon Center. 

The first moment that would define Sara Pullen’s career came before she had even graduated from her physical therapy program. “I always knew that I wanted to combine my love of medicine with working with disenfranchised populations,” explains Pullen, now an assistant professor of physical therapy at Emory.

Pullen had no idea how to pull together her different passions. But then she started her first clinical rotation and 
met a patient living with AIDS. The patient told her that hospital social workers had referred him to Meals on Wheels and other community resources. “But I don’t want that,” the man said. “I want to get stronger.”

It was the mid 1990s, and few people with AIDS had received physical therapy as part of their treatment. Yet Pullen was determined to put her new skills to use with the patient. “At the end of his time in PT, he was completely independent and didn’t need any assistance,” she recalls.

A few years later, Pullen found herself working with another patient, a person living with end-stage AIDS. “He just wanted to be able to wheel his wheelchair outside to sit in the sun before he died,” Pullen recalls. “That was his physical therapy goal.”

The two experiences gave Pullen a preview into the importance of physical therapy in treating HIV. “These were two different patients with different needs, but they both really needed physical therapy,” says Pullen, DPT, MPH, CHES, who now directs the service-learning program at Emory’s Division of Physical Therapy and also coordinates Emory’s dual-degree DPT/MPH program.

And so it started: a career focused on bringing clinical care and the benefits of academic scholarship to patients living with HIV. As such, it’s been a career of firsts. Pullen is the first and only physical therapist affiliated with Emory’s NIH-funded Center for AIDS Research (CFAR). She’s the first and only physical therapist at the Ponce de Leon Center in Atlanta, one of the country’s largest AIDS clinics and a core facility for CFAR. And she’s one of the first people researching physical therapy as a treatment for the chronic, debilitating pain often associated with HIV/AIDS. “The work I’m doing isn’t really part of the canon of HIV or PT research,” says Pullen. “I’m meeting in the middle and saying let’s make this work part of both.”

Pullen’s work is possible only because of how far HIV/AIDS treatment has come. From the 1980s until the mid 1990s physical therapy was, in most respects, irrelevant. Regardless of interventions, Pullen says, “the end point was that you’d die of AIDS-related complications.”

Today a diagnosis of HIV is no longer a death sentence, thanks to antiretroviral therapy and careful medical management. In fact, a 2013 study published in PLOS ONE found that people with HIV who start antiretroviral therapy at age 20 may now live into their 70s.

As a result, people living with HIV now need medical treatment that goes far beyond palliative care. Yet many health care providers are unaware of how to best help people with HIV. “It’s not just take a pill and you’ll be fine,” says Pullen. “There are medication and disease-related complications as well as musculoskeletal and neuromuscular issues that come with HIV.”

In addition, those living with HIV are more likely than others to experience chronic pain.

Kimbi Hagen, EdD, an associate director at CFAR, explains: “HIV itself and the antiretrovirals that are prescribed to control it can independently and synergistically cause bone loss, which leads to musculoskeletal problems and lots of pain—think of the ‘foot bone connected to the ankle bone connected to the leg bone’ song we all heard as children. HIV-associated neurologic issues can also lead to gait changes, which decrease mobility and lead to or exacerbate chronic pain as well.” 

While research until now has been limited, physical therapy has become a widely accepted treatment for patients with HIV. “What physical therapy can do is decrease HIV-related impairments and thereby reduce pain and improve quality of life,” says Pullen.

About five years ago, early in her time on faculty at Emory, Pullen met with leaders at the Ponce de Leon Center, which is known for providing integrated care to thousands of mostly low-income patients, offering access to mental health counselors, addiction treatment, a dental clinic, and primary care—all in-house to make access easier for patients. “But the center did not have physical therapy, and there was a need for it,” Pullen says. She conducted a needs assessment, talking to providers and patients, and soon began seeing patients there one day a week.

“I call it clinical utopia,” says Pullen. “The center is doing innovative interdisciplinary work with patients.” When a patient comes in for physical therapy but clearly has a mental health issue that needs to be triaged, Pullen can quickly find a psychotherapist on site to help stabilize the patient. “Or if I have a patient with a medical issue that’s beyond my scope of practice, I can literally walk down the hall, find a physician, and say, ‘Can I run something by you?’ and we’ll talk right then.” As a result, says Pullen, “The patients do really well there.”

When Pullen first started working with patients at the Ponce Center, she found she could significantly decrease their pain and their dependence on highly addictive prescription painkillers by teaching them physical therapy exercises.

“It’s transformation,” says Melody Palmore, MD, director of women’s programs at the Ponce Center. Many of Palmore’s patients work on their feet all day and have struggled with arthritic knee pain. After physical therapy with Pullen, Palmore’s patients began telling her their pain had decreased or was gone all together. “They’re radiant. What was debilitating to them 
has been lifted, and they can concentrate now on other things.”

In fact, Ponce Center doctors began noticing that overall adherence to medical care improved after physical therapy became part of the treatment regimen. Patients who would previously miss appointments because they were in too much pain started showing up. It was easier for them to get to a pharmacy to fill a prescription. It was easier to stick to an exercise plan, reducing the severity of hypertension or diabetes issues. ”It’s removing another barrier for them to participate in their care,” says Palmore.

CFAR’s Hagen started to take notice. “I began hearing over and over about this amazing physical therapist, Sara Pullen, who was seeing patients part-time at the clinic,” says Hagen. “Doctors couldn’t believe how much pain relief physical therapy could help their patients achieve without the use of drugs.”

Then in 2015, Pullen called Hagen to say she was interested in doing research through CFAR. Soon after, Pullen was selected as a junior HIV researcher and matched with experienced CFAR investigator mentors to help her grow as an HIV researcher. Along with Palmore, Pullen was matched with Vincent Marconi, Emory professor of medicine and past associate medical director of the Ponce de Leon Center. She was also matched with Emory nursing professor Marcia Holsted, PhD, RN-C, FNP.

“Being connected with CFAR has been a game-changer for me,” says Pullen. “Physical therapy hasn’t traditionally been part of the big picture of HIV care but because now we have these long-term HIV survivors there really is this need. The mentorship I’ve gotten from these globally recognized HIV researchers has been invaluable.”

Under the guidance of Palmore, Marconi, and Holstad, Pullen soon began applying for NIH grants and also began research funded through CFAR. In an initial study at the Ponce Center, she tracked 46 research participants who described having pain in their lower back or lower or upper extremities. The majority had been living with this pain for a year or more. Physical therapy interventions included progressive resistive exercise, passive stretch, massage, postural education, and taping.

The results affirmed what Pullen and her colleagues have intuited through their clinical work. In a paper at the New York Academy of Sciences presented earlier this year, Pullen described her results: 75 percent of patients experienced meaningful decrease in pain levels as a result of their physical therapy treatment. As a result, participants had generally decreased their use and reliance on pain medications by the end of the study.

Holstad says the implications of this research are substantial for clinician care, future advocacy, and research. “Research to examine physical therapy’s impact on these conditions in HIV-positive persons is important for clinical management of these patients,” she says.

Hagan agrees, adding that research may have some additional benefits. “Given the rising concern over the growth of opioid addictions, research showing the value of non-drug therapy for chronic pain in HIV is very timely.” She adds, “It might also help bolster support for insurance coverage of PT for these patients.”

Pullen’s upcoming projects include research comparing chronic pain of patients receiving physical therapy with pain experienced by patients who have not. She’s also beginning a study of the prevalence of disability among people living with HIV in Atlanta.

Pullen is also continuing to see patients at the Ponce Center. “Clinical work allows me to see in real time what the needs are, where the needs are, and where I should focus my attention,” 
says Pullen.

Pullen’s colleagues in HIV research and treatment have gained new appreciation for the value of physical therapy. “She’s definitely blazing a trail,” says Palmore. Hagen adds, “My new rallying cry is, ‘a PT in every HIV clinic!’”

Pullen is grateful that she has been able to fulfill her early-career aspirations of focusing on care for marginalized populations. “It feels good to wake up every morning knowing that I’m using my skills and education with people who have often been neglected by society.”

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