Goal Selection and Optimization Process for Patient Activities

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the theory of selective optimization & customization, including how to help patients select goals, optimizing treatment around goals, and being OK with compensation as needed.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

JEFF MUSGRAVEWelcome to the PT on Ice Daily Show. I'm going to be your host today, Dr. Jeff Musgrave, Doctor of Physical Therapy. It is Wednesday. That means it is all things geriatrics today. So excited to be sharing with you a topic fresh off a really exciting trip, Preparing for Adventure and the SOC Model. Now, don't get sick to your stomach if you're a home health clinician. We're not talking about start of care, okay? We're talking about a theory for successful aging.

THE STRONGER LIFE RETREAT So I'm gonna give you a little bit of background on how I got to this topic and why I'm excited to share it with you. just came off a trip out of the country with 20 members that are 55 and older. So we took an adventure retreat. Stronger Life members joined us out of the country to seek adventure and this was a really incredible experience. If I was preparing one of these members from a formal PT standpoint, what would I want to be thinking about? How would I select the goal? How would I optimize? When do we compensate for these patients? So if you're preparing someone for adventure, we need to be thinking about all these things. BALT's successful theory on aging has been a really helpful framework we use very frequently in our division, the older adult division. And what we want to do is, Adventure is relative, right? So we're taking 20 members from Stronger Life to the Dominican Republic where they're going to go snorkeling, where they're going to go horseback riding, where they're going to be walking or running on the beach, they're going to be swimming in the ocean, they're going to be kayaking in the ocean, all these exciting things. But adventure is relative. So maybe the patient in front of you, adventure for them is going to their grandson's baseball game. that may be a big overwhelming task that you need to break down. Or maybe it's just going for a walk outside. Maybe you've got a primarily homebound population and going outside feels like a big adventure. So I am going to use this higher level adventure example because it's fun, interesting, and fresh for me coming off this trip, which was so much fun. But for you, know that all of these things are scalable and this framework is going to be relative regardless. of the functional level of the client in front of you.

SELECTIVE OPTIMIZATION AND COMPENSATION So just a little bit more on this SOC model. So Selection Optimization and Compensation. So this has been a tenet of Lifespan Psychology and the process of development that entails Losses and gains of our patients over time. We know that in general, our patients who are not seeking fitness, who are going through this period of time where they're in a decline, if we can't interact with some fitness and get them active, we know it's gonna look like this. But for many of our clients that we're taking this fitness forward approach, there's gonna be gains and losses over time. And what we wanna do is we wanna learn how to partner with them in this aging process, knowing that there are some changes, despite our best efforts, things we can't change. We're really comfortable with things we know we can change, but we have a little more trouble when we bump into barriers and things we can't move forward. So this model, SOC, Selection, Optimization, Compensation, looking at the full lifespan and learning how to use these three tools.

SELECTION So the first tool is selection. So when we're talking about selection and we're thinking about older adults and their goals and successful aging for them, we're talking about goals that matter to them, not these BS goals like get better, get out of the hospital, feel better. Those things are things our patients may report to us, but it's our job to dig deeper and figure out why and why they feel that way and what specifically that means to them. So finding that meaningful goal and what they want to accomplish, we've got to break it down and get as specific as possible. The more effort we can put on the front end with selecting a meaningful goal and really understanding what that means, it makes the rest of our job so much easier. When it's time to select exercises, we're trying to figure out what tests and measures we need to be looking at. It becomes so much more clear. So a good start, I'll give you an example. We had lots of members who were planning to go horseback riding for the first time, or first time since they were in their teens. And if I had that client in the clinic, I'm seeing them in the fitness realm currently, but if I was seeing them in the clinic, the questions I would ask based on this framework of selection are, when is this gonna occur? When's our goal need to be accomplished? I would also want to know what's amounting, you know, excuse me. So when's this going to occur? How long are you going to ride? How big is the horse you're getting on? How frequently do you want to ride while you're gone? What gate is this horse going to going to experience? Is this member going to just be doing a slow walk? Are they going to be trotting where they're going to be oscillating up and down which may stimulate the vestibular system? Are they going to be cantering? How much dynamic balance do they need? How much strength do they need to be able to hold their position on the horse? So based on the frequency, the duration, the size of the horse, how often they want to do this, this is really going to help us break down what our patient needs specifically to reach this goal. And reminder, we're going to go through this same process if someone needs to carry their groceries in. We want to select a meaningful goal for them, then we need to break it down. We need to have all the specifics possible at our fingertips. So we want to know the strength, the range of motion requirements, the endurance requirements, the balance requirements, the vestibular requirements, which in this case are very relevant. When you think about the movement of someone on a horse, they're going to be going up and down. That's going to be stimulating the inner ear system, the utricle and the saccule as they accelerate, decelerate. There's going to be head turning. They're on a beautiful beach riding a horse. They're going to be turning their head, looking at stuff or trying to talk to their friends or get some selfies going. during that time. So we want to be as specific as possible to figure out what in the world they are going to need to be able to accomplish this goal. So selection is the first piece. We want to select a meaningful goal to them and we want to get as much information as possible.

OPTIMIZATION Once we have all the specifics nailed down, We're going to go on to the next step. And this is where most of us shine is optimization. So the first piece is selection. The second is optimization. Based on where this patient is starting, And the goal, we now have a start and a finish line. We've got to get accurate measurements at the beginning. Our CEO, Jeff Moore, is very famous for saying you can't make good decisions with bad data. We want to be specific of the conditions we're testing. We want to be accurate so we can actually see if we're making change in the future. Otherwise, we might as well not measure, by and large. So we want to be very specific with those measurements. But now we know This person wants to go horseback riding once. It's going to last about 45 minutes. They want to walk. They don't care if they canter or trot. They're going to be on the beach, so they're going to have to walk across the beach to be able to get there. So we now, we're going to say those are the specifics that the patient gave us. So now we're going to be looking at the range of motion of their hips. We're going to say, oh, these are going to be small island horses. There's not as much hip abduction required. We know that we don't have to get them stable in a seated position for a canter or a gallop. We just got to be steady in this seated position for 30, 45 minutes one time. And then we're going to, you know, hopefully the mounting situation we've asked about as well. Are they going to be able to go up steps unsupported to get on this horse? Or are they going to need, in the equestrian world, a leg up? Is someone going to come over and help boost them into position? So once we've got all that information, we've checked the range of motion, strength, balance, vestibular requirements, then we're going to go to work, right? We're going to challenge all of these different systems to reach this big, meaningful goal. range of motion that they need to really make this happen. We want to make sure that we're, you know, not laying on the table, kicking our legs, sitting, or outside of these positions that aren't relative to the goal. We want to make sure that these are big functional movements. We want to make sure that it mimics this movement and this activity as much as possible. Being in a seated position, can they go up and down, accelerate back and forth? There are lots of creative ways to do this on Swiss falls or if you're on, on a rolling chair going back and forth and adding some head turns. There's lots of ways we can replicate this. Even the mounting situation where we can use a high-low table and get really creative and maybe we're getting them onto a bolster or a Bosu ball, something like that. But during this optimization, we've got to make it as much like the actual goal as possible, as quickly as possible. That's going to help us with buy-in, And we know from motor learning, just in general, the more it replicates the actual activity and the conditions. I mean, heck, we can play some seagulls and some ocean music. We could do these things outside with distractions. There's lots of ways to layer in all the specifics that we gained from the first piece of selecting the goal. But once we know the optimization period, we've got to replicate that as much as possible.

COMPENSATION Once it's time for the third piece is compensation. This is the part that we get really uncomfortable. Most of us in the rehab world, we want to restore function as much as possible, and that's not a bad thing. We want to do that, but sometimes we don't have enough runway. The patient doesn't come to us in enough time. We can't help them change quickly enough to meet that goal on time. And if we want the goal to be accomplished, we're going to have to compensate. Oftentimes, our OT colleagues are much better at this. They're like, hey, just use the tool. Let's make this thing happen. Most of us that are physical therapists, fitness pros, we want to see people get stronger and we get really uncomfortable when it's time to compensate. but there are simple ways, little on-ramps, like getting a leg up, practicing having someone help them get on the horse, versus saying, you know what, you just can't mount on your own, so I don't think it's a good idea for you to do this, or you don't have quite enough range of motion to be able to throw your leg up behind the horse, for example, so this is really out of the question, versus saying, hey, can we have someone support you? Is someone else going on this trip? Can you bring someone into the office and we can replicate this mounting situation to give them a leg up, swing their leg around the horse, and help them be stable. Heck, even sometimes we can have someone walk alongside them to help keep them steady. If the goal is meaningful enough, we can accomplish it with some compensation. So whether it's an adventure retreat, whether it's a patient that needs to walk outside, get thrown groceries, go to a kid's baseball game for the first time, adventure is relative to the person in front of you. Regardless of that, a great framework, keeping in mind that compensation and changes in capacity happen over time, our BALT's theory of successful aging. So we wanna make sure that we're selecting meaningful goals to the patient, We're optimizing all the systems, getting good baseline data, and then if all else fails, we need to compensate to make those goals happen.

SUMMARY Team, I hope this was interesting. I hope this was helpful for you. If you're looking to catch us out on the road, We're gonna be in Newton, Kansas. I'll be there on the 16th and 17th, and then Madison, Wisconsin, we'll be there March 23rd and 24th. If you're trying to hop into one of our online courses, lucky for you, level one course is going to open up on March 13th, and then not long after that, we'll have level two. So I hope you enjoyed this. If you have any questions, comments, please drop them for me. I hope you have a wonderful day, and that's it for now, team.

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