High Intensity Training and Objective Measures in Geriatric Rehabilitation

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses the top 4 "ins" and "outs" to geriatric practice in 2024.

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.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. CHRISTINA PREVETT Hello everybody and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of the lead faculty within our geriatric and pelvic health divisions and happy 2024. So I'm really excited because I have been seeing these like ins and outs of 2024 all over social media and I thought they were so fun. And therefore, I wanted to try and do the same thing for geriatric practice. I think it'd be so fun. So in today's episode, I am gonna be doing four ins and four outs for 2024 for geriatric practice. IN #1: HIGH-INTENSITY So the first, we're gonna start with the ins. And the first one that you know if you've been following MMA for any amount of time is we are going to put high intensity everywhere. And we recognize that high intensity is relative, but we have actually updated our content in the last year to just reflect that we cannot ignore intensity anymore. And that doesn't say that we're gonna ignore the accumulated effects of low to moderate intensity exercise. That's absolutely not it. It's that we cannot be afraid of high intensity exercise anymore when we have overwhelming evidence across all life stages and across a variety of different chronic conditions. So when we have octogenarians and individuals with lung cancer and individuals who have had a stroke who are successfully able to participate in high intensity endurance training or aerobic training, We can't ignore it anymore. It's just the evidence is just too strong. And so that is going to be our in is to push every single day to do something a little bit higher intensity than we previously would and play around with intensity as a variable. That's number one, high intensity everything. IN #2: USE OBJECTIVE MEASURES THAT MATTER Number two is that we need to get objective measures that matter. When we teach at MMOA Live, we always look around the room before we start our outcome measures lab, and we try and make outcome measures fun, I promise. I think it's fun anyway. We ask individuals, how many people are having a goal for their geriatric patients that are they need to get objectively stronger? everybody puts up their hands right if you're older adult can't get out of a chair without using their hands like their leg strength is less than their body weight which is a dangerous place for them to be because what happens if they they break their wrist and so that is almost everybody says yes this is what I want them to do when we ask how do you how many people take an objective measure of strengths that they know is that they're prescribing in the right intensity zones, that is usually a lot less. That's a lot less people putting up their hands. And I get it, we think that we have to wonder at max deadlift with somebody and that seems absolutely ridiculous for some of our patients who are maybe seated a lot of the time or have a lot of frailty on board, but that's not the case. That's not the way that we need to do or we need to always think about objective intensity. We have different ways. And so our in for 2024, number two, is that objective measures for function matter. And we are not going to know if we're hitting the right spot. There's always this Goldilocks equation, right? Like I've had people mad at me because I've been a little bit too hot on the intensity, but I've also left a lot on the table from being a little bit too cold. So we have to be able to objectively measure where we need to be and we need to know what we can do in order to hit those targets. So that's number two. IN #3: PRIORITIZING A FITNESS-FORWARD APPROACH TO GERIATRIC CARE Number three is that we need to start prioritizing a fitness-forward approach to geriatric care. And I know, you know, I would probably say that the geriatric space, with so much being involved in balance, false prevention, we're not as manual therapy focused. We always joke at ICE that, you know, which ones are our gericrew, because our hands are just not nearly as good as some of our orthopedic outpatient therapists. But There's this idea when we start talking about kettlebells and heavy bands and barbells that fitness forward approach and geriatric care is expensive. And our MMA crew, we have to just laugh. Like we laugh and laugh and laugh because if you look at the cost of a new step, our clinics are not hesitating to buy a $10,000 piece of cardio equipment but do not want to put in $1,000 in order for them to be able to get some true measurable objective strength training equipment. And Alan tells me, because he's a guru in this stuff, that you can get a lot of that reimbursed through a tax credit. So it is not as expensive as you think, and it doesn't have to be as in-depth as we are thinking when it comes to buying fitness forward equipment. And for our home healthers or those that are traveling, you know, having a heavy road ban and having one or two kettlebells in your car is not a huge investment. And it's absolutely something that we can do in order for us to take a fitness forward approach to rehab. So we have one high-intensity everything, two objective measures that matter, that give us information, and three is just prioritizing that fitness forward approach. IN #4: POST-MENOPAUSAL ACCESS TO HORMONE REPLACEMENT THERAPY And then number four, I have to put my Jerry UI, Jerry pelvic hat on, is that we're going to start removing some of these barriers for women who are post-menopausal to access HRT. There is a big push right now because we see, for example, that topical estrogens can significantly reduce rates of urinary tract infections. Urinary tract infections are absolutely devastating for some of our older adults. And there is a lot of fear. I'm pushing against it every single day in the clinic when I'm working with someone post-menopausal and I bring up estrogen and they say, I talked to my doctor and they said it's dangerous. It's going to give me cancer. they're not prescribing it and that is just so behind the times and that is not where we want to be so in 2023 going into we're going to get rid of it 2024 we're going to be advocates for it and we're going to have our own knowledge to be able to be able to give our clients up-to-date information about something that can significantly impact their health. I was just reading a cross-sectional survey on menopausal women who were active, and it showed that 68% of them, as they went through the menopausal transition, had an increase in joints, aches, and pains, which means that we're missing something oftentimes in our assessments if we're not trying to take into account estrogen status with how they're presenting in the clinic. So there are our four M's, high-intensity everything, objective measures that matter, a fitness-forward approach, and it isn't that expensive, and using HRT for menopausal women who may be eligible for it. OUT #1: DISMISSAL OF COMPLAINTS DUE TO AGE So let's talk about our outs. What are we going to kick out in 2024? Number one is we are going to kick out these dismissal of complaints based on age. We are going to kick them to the curb. Almost every condition in our medical system has age as a risk factor. The longer we are on this earth, the more wrinkles we have on our insides, we have on our vessels, we have in our organs. Yes, it is an increased risk for orthopedic musculoskeletal pain, for different signs and symptoms of functions at different organ systems, yes. but saying that it's because you are such age or that you should not have the expectations to feel healthy and vibrant at 70 because you're 70, that is not okay. We are going to stop dismissing complaints, stop saying things as physios like, of course you have bone and bone arthritis, you're gonna have pain in your knee or you're over the age of 60, pain is never going to be completely gone. You're never gonna be pain free again. Things that I've heard from a rehab clinicians in my area We need to stop dismissing complaints. OUT #2: ELDER SPEAK The second thing is elder speak. We're going to kick elder speak to the curb. Oh, I have a 99 year old. She's so cute. She was a surgeon. She has raised 10 children and has 25 grandchildren and is still a really active part of her family. I hear this on our courses all the time. Oh, I have the cutest 75 year old. It is meant well, but it is dismissing or infantilizing our older adults that deserve our respect and reverence. And so we are going to adamantly hold that line. And kind of our to be to this is we're gonna really focus on using patient first language. So many times when we ask like, tell me who you're going to work with to implement some of these things from MMOA on Monday, we say, I have a stroke that is 75. instead of saying, I have a person who had a stroke, who is 75. And it can completely dehumanize them. And we do it for quickness of communication often, but it is definitely something that we need to be better at in order to allow individuals to not have their disease central to their wellbeing and their identifiers as a person, right? We see this all the time, that individuals start to become their diseases. And if we speak like that, then it becomes so much easier for that to happen, right? We do not want to say you are your stroke. You are a person who is hopefully going to live a very high quality multidimensional life with impairments that you did not have before, but you are not your stroke. So I kind of put that as an elder speak bee, okay? So the first thing we're going to make sure we kick out is dismissing complaints based on age. The second thing is we're going to watch our own communication. We're going to kick out elder speak. We're going to kick out this patient first language, or we're going to use this patient first language. We're going to kick out identifying individuals as a shoulder or a knee, or I have a total joint replacement. Got three knees and a hip on my schedule. We're going to kick all that language out because it starts with the way that we communicate in our minds and with our colleagues, and then it trickles into the way that we communicate with our patients. OUT #3: BLANKET CONTRAINDICATIONS The third thing, this might be a little bit of a lofty goal, but I'm gonna say it anyway. We're gonna start removing blanket contraindications, right? If you've kind of been around our crew, you know that the bed lift twist restrictions after things like lumbar surgery, people go to the bathroom the first day, they're bending right away. They just have to be taught how to bend or something. We know that our hip precautions don't really do anything. And we have all seen that patient that comes in 10 years later after getting a stent done and says, well, I can't lift more than 20 pounds. I had heart surgery in 2014. And we're like, whoa, whoa, whoa, whoa, whoa. What are we talking about here? We need to DC those recommendations. So what we're starting to see over and over again is that blanket recommendations are kind of done based on theory of tissue healing. But we know as rehab clinicians that they all respond to stress. Right, our body needs to gradually reintroduce stress across a graft, across a surgical stalcar, across an injury, and that needs to be done in a nuanced, individualized approach, and these blanket recommendations oftentimes do not really help, and what they do do is create a lot of kinesiophobia. And oftentimes, because of the way that our medical systems are set up, where we don't have appropriate or adequate follow-up, because we're just so overrun with a lot of different medical professions, they don't get discharged. And so we wanna try and be really mindful of that. All right, elder speak, A and B, dismissing complaints, blanket contraindications, and then the last one, and I'm gonna end here, is that we are going to avoid taking a siloed approach to our rehab. OUT #4: SILO APPROACHES TO HEALTHCARE So often, PTs are not tapping the shoulders of our OTs, our speech-language pathologists, our social workers, our nurse practitioners, our pharmacists, and we think that we need to know all the answers. It is funny, the more education that I get, the more I realize how much I do not know. Every time we are doing a course, I get somebody teach me something new and We don't need to. We don't need to know everything because we have our colleagues. We have our friends. Our healthcare system is meant to be a multidisciplinary collaborative. process. And I know you all are looking at me being like, well, you know, it's got to go both ways. And I totally agree, especially with our physician spaces. And that is something that I'm really passionate about advocating for as well, is letting our physicians as well kind of pass the baton and say, I don't have the space, I don't have the knowledge, but this person does. And so what I want to see get kicked out in 2024 is this idea that we are our own island. because it just makes our patients feel so alone or so unheard. because the communication doesn't go back and forth. In our medical professions, we're starting to become so hyper-specialized that sometimes we only look at the tree and we don't see the forest. This is where our PTs, OTs, rehab clinicians, we do a good job of zooming out, but sometimes we put ourselves in these silos too. I'm not a pelvic floor PT, so I'm not gonna talk about your pelvic floor despite the fact that the reason why you're not exercising with me is because you're peeing every single time. I'm not a vestibular specialist, so you're gonna tell me that you're dizzy, but that's not in my wheelhouse, so I'm not going to talk about it, even though it's the biggest barrier to you exercising, right? These are all things that we silo ourselves within our profession, and then we don't often tap on or even look for other clinicians in our area that could be helping our patients. And so we wanna take this siloed approach, kick it out, and kind of an in is that we're gonna really try and lean on relationships with our colleagues. And it's hard in a really busy clinic, I get it, but we absolutely have a role to play and we want to lean on them so that we know what they are capable of. And so we wanna even know their scope of practice. So we have so much, so much work to do. SUMMARY So looping this around, what are our ins? High-intensity everything, objective measures that matter, a fitness-forward approach, and using HRT for menopausal females. What are our outs? We're not going to dismiss complaints because of age and just say, well, you're 80 years old. Nope. We are not going to communicate with elder speak or avoid patient first language. We are going to maybe hopefully get rid of some of these blanket contraindications, take a very gradual approach. And then we are going to kick out the siloed approach to rehab. Alright, if you are looking to catch MMA, our Level 1 and Level 2 courses. Level 1 starts January 10th, formerly known as Essential Foundations. Our Level 2 starts January 11th. If you are trying to see us on the road, our first courses back start the 13th, 14th. So we are in Maryville, Ohio, and we are in Santa Rosa, California, the 13th, 14th, and then the 20th to the 21st, we are in Clearwater, Florida, or you can catch me in Greenville, South Carolina. So hopefully we will see you on the road sometime this year, or we'll see you in our courses. We have some big, exciting changes that are coming around the ICE pipeline. So stay tuned, have a great day, everyone, and happy 2024.

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