Physical activity is an important factor in preventing chronic disease, and higher levels of physical activity are correlated with improved physical function in community-dwelling older adults (Halaweh et al., 2017). A Swedish study identified access to exercise facilities as a factor that positively impacts the likelihood of meeting weekly physical activity recommendations (Eriksson et al., 2012). As shelter-in-place orders rolled out across the United States in response to the COVID-19 pandemic, routines outside of the home were abruptly halted. The need for physical distancing to slow the spread of a virus, and the particular vulnerability of individuals of advanced age and those with preexisting medical conditions, created a population that one might call "temporarily homebound." In many locations, shelter-in-place orders extended to months instead of weeks, and even when lifted, the individuals at high risk for severe complications from COVID-19 were asked to continue to stay home (Centers for Disease Control and Prevention, 2021). Prior to the pandemic, many of these individuals were independent and often extremely physically and socially active. They may have held part-time or full-time jobs, volunteered regularly in their communities, or participated in recreational sports and other leisure activities. The sudden loss of access to fitness facilities and decrease in community activities create concern for decline in physical activity and subsequent functional decline in this "temporarily homebound" population.

At the time of this writing, there is limited evidence specific to physical activity or physical fitness decline during quarantine in high-risk groups; however, one recent study concluded that the COVID-19 quarantine was more detrimental to the physical conditioning of professional soccer players than a typical off-season, after players performed home workouts using only body weight for resistance during a 63-day quarantine, and then performed their usual preseason physical fitness testing upon return (Grazioli et al., 2020). Considering this loss of physical function in a healthy athletic population, it is plausible to hypothesize other populations have also experienced a loss in physical function.

Individuals with chronic neuromusculoskeletal conditions may have been especially vulnerable to functional decline during this time. Among the contributing factors are the potential for exacerbation of preexisting load-bearing joint pathology associated with increased use of body weight exercises, a common exercise mode in the home environment. Additionally, full participation in the types of exercise available in the home may be hindered by safety concerns associated with balance deficits. A case example highlighting the aforementioned pandemic-induced exercise barriers is one of a 71-year-old female with bilateral knee osteoarthritis. This patient has been a candidate for total knee replacement for several years based on the degree of joint degeneration present. She had delayed surgery and maintained her physical function and high quality of life using hyaluronic acid injections, a regular routine of walking and gentle strength training at a local fitness center, lifestyle physical activity through her part-time job and social activities, and occasional physical therapy "tune-ups." Her medical history includes asthma that motivated her strict adherence to the precautions advised by the Centers for Disease Control and Prevention for those at high risk for serious complications of COVID-19. She has been "temporarily homebound" for 10 months at the time of this writing. She is not able to work at her part-time job caring for children before and after school, is not taking her usual four to five weekly trips to the gym, and is having all basic needs delivered to her home. She continues to walk her dog twice daily, and initially began participating in online exercise classes for individuals age 65 years and older, but the classes exacerbated knee pain and inflammation. The patient chose to stop participating in the online exercise classes and was able to manage the exacerbation with a corticosteroid injection from her orthopedic physician and three sessions of manual physical therapy in her home. The patient is now independently performing a full-body exercise routine at home designed by her physical therapist to protect her knees. She notes the exercise doesn't give her quite the same challenge or excitement as the equipment at the gym, but she plans to continue because she understands she needs to keep exercising in a way that does not cause her knees to flare up. When she feels it is safe to return to the gym, she plans to contact her physical therapist for advice on gradual reintroduction of her usual routine. There are likely hundreds of variations of this story, and this patient is fortunate to have a relationship with a physical therapist she trusts to help her navigate her current homebound status and successfully reengage with her community when she feels safe doing so.

Home healthcare physical therapists have an opportunity to step into consultative and wellness promotion roles and direct these "temporarily homebound" individuals to the level of physical support they need to begin to reengage. Evidence for one physical therapy initiative that targets an at-risk community-dwelling older population referred from community senior centers has emerging evidence that it brings about positive health changes and reduces fall risk (Arena et al., 2020). Current public health concerns warrant casting a wide net into the home healthcare arena to encompass individuals whose physical activity decline or complication risk from COVID-19 may ultimately result in the individual becoming permanently homebound. By engaging healthcare colleagues and local community members in conversations about the role of physical therapy in restoring participation, physical therapists are positioned to support the "temporarily homebound" in maintaining physical function and safely reengaging with their communities in the coming months as pandemic precautions are lifted.

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