Recognizing the Barriers Clinicians Face in Implementing Change

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how it can feel very overwhelming when your practice looks very different then what you are exposed to in a course like Modern Management of the Older Adult. You don't need to change drastically overnight (though you can!) but we encourage you to take the first step. In today's episode, Christina takes you through 4 steps you can take TODAY, to level up

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 division. And today I wanted to talk to you about something that we see a lot as we talk to clinicians across the country, across North America, sometimes internationally, about some of the barriers to implementing some of these exercise interventions that we know are so, so relevant and helpful to get our older adults as strong as possible, to give them as much reserve as possible. So when we go into different live courses, we have our two-day online, or we have our eight-week online course, we have our two-day live course. We talk to clinicians in the geriatric space who are in a lot of different practice settings, right? It's really great and really unique that one, we oftentimes have a multidisciplinary group. So we're seeing OTs, PTs, CODAs, PTAs. But then we also have a lot of people in the room who are in different practice settings. So in any course, we can have some people who are in acute care, in home health, in skilled nursing facilities, long-term care facilities, outpatient clinics, fitness. We kind of see this spectrum, right? And we know that with our older adults, that there is a spectrum. And in our courses, we try to speak to that spectrum. So we try to speak to the clinician who is working with really sick folks in the hospital, to the, person who's in fitness and is keeping older adults who are doing fairly well as active as they can into hopefully their 90s and 100s. But sometimes there can be these barriers that are maybe not to do with the client that you're seeing, but the clinician and the space at which the clinician is at in order for it to feel like an overwhelming barrier to get individuals to or to see some of the changes we know are going to lead to better outcomes. And this is not to cast any blame on the clinician, but to acknowledge that it is not just you working with the client, it's you working with the client within the system that is medicine and the system that is your employer. And it's something that we want to acknowledge. So I was at a course recently and I had a person come up to me and I just, I loved the vulnerability, but she said to me, you know, I am a worse clinician than I was five years ago. And she was, she's about five, six years out. And you know, I'm going to talk about what you can do today, but I want to acknowledge this first. And she said, I'm just so tired. And she wasn't saying it for, you know, sympathy. She was just wanting an acknowledgement that she knew that all of the things that we were talking about in this course were exactly what she needed to be doing. And yet all of the other stuff around the system that she was experiencing was making it so that she was exhausted and it made it hard to do the better thing, right? Because Seated Therax is not as cognitively demanding on us as clinicians. The safety profile is oftentimes a lot lower, is a lot lower, even if the returns are not as good. And I first, before we start talking about ways that we can start leveling up our therapy practice, like what is the next step that we can take? If this story is resonating with you, what I want you to do is know that we see you. We see how hard clinicians are working. We see how hard it can be to push back against a narrative that has been, you know, kind of placed into our system that makes it so that there are barriers that are systems and administrative barriers that make, you know, leveling up in geriatrics be difficult to do. It is especially difficult if you are the one trying to push against this and everybody else in your practice is not. And so I first want to just acknowledge you and say, you know, I'm going to start trying to give some practical tips around ways that you can take that next step. But if your biggest barrier is where you are at from a headspace perspective or where you are at from a cultural perspective, just know that I acknowledge that where you are. and maybe some of that reflection will help work towards, you know, I don't know what that next step is for you to try and help get you out of that burnout or out of that exhaustion state, but it may be your biggest hurdle when it comes to leveling up in the geriatric space. So I wanted to acknowledge that first. "WHERE DO I START?" Okay, so the next step is I have no idea where to start. and I have no idea what to do. And so where I want all of you to start, and this is gonna be my challenge for you for the rest of the week, is do one thing different. level up in one thing. So when people come and take our course, they think, okay, now everything that I do has to be different. And that would be like taking you and you eat fast food six times a day or six times a week and you don't exercise at all and you're not sleeping and you're over caffeinated and you don't know what water is. And then you say, okay, I'm going to go and I'm going to eat super clean. I'm never going to have any fast food ever again. I'm just going to drink water. I'm going to kick out caffeine and I'm going to exercise 150 minutes. of aerobic and two times a week of strength training. I love that goal for you, but we wanna make it so that it makes what seems impossible possible. And we're gonna start taking these little steps, right? So we talk a lot in MMA about graded exposure and acknowledging that process when it comes to our patients, but we acknowledge that that practice change also takes time. And if this is not an area where you are focusing with respect to intensity, and this is particularly true in the resistance training space, just know that we don't need to drastically change. LAYER IN STANDING EXERCISES We need to take the next step. And so what can that be? Let's go through three examples of what that can look like. So you have a patient who is coming in and you have been doing predominantly seated exercise. and this is no shame at all. This is where you are at with this person. They are tired, their joints are irritable, and you know that you're gonna have to do a lot of pressing to get that session to be mostly in standing. Great. I want you to get them standing for one. If that's one exercise, that's one set. If you are doing long arc quad, change that to a standing terminal knee extension with a band around the rig or around a doorknob or around the high-low table that allows them to do that exercise in standing. So the one next step can be is to choose one person on your caseload where the easier choice was to do the seated option, but you're going to get them to do the standing option. So that's taking the step Here, that was number one. START USING AMRAP SETS Number two, if you are a person who has had trouble finding a quantifiable baseline assessment of strength. And this is so many people in our profession, like we ask all the time, like how many people take a kind of estimated strength measurement before they prescribe strength exercise? And most people are saying, well, shoot, I don't really do that. And it was a big growth area for me too. So the first opportunity for leveling up, today in your geriatric practice is to get a person who you would have chose a seated option, but you're going to try and get them into standing for at least one set. The second one is going to be to pick one exercise for one person and do an AMRAP set. So we talk about using estimated 100 maxes. So an AMRAP set is as many repetitions as possible. We can use it for a quantifiable baseline amount of strength, You're going to choose a weight that you think individuals can do for 10 repetitions or less because there's a cardiovascular component if we're over 10, if you've ever lifted heavy weights for more than 10 reps, you know what I'm talking about. And I want you to put an AMRAP set in today. So that's number two. Number three is you take one person's session and you get an objective measure for every set. So this is my number three. So one is get a person in standing if we want to have them sitting even though we know they can stand. Number two is getting an AMRAP set to try and find a quantifiable baseline amount of strength. BEGIN TO OBJECTIVELY QUANTITY EFFORT WITH RPE And three is to find a rate using a rating of perceived exertion, an RPE, for each exercise. and try and get individuals in that moderate sweet spot between five and seven. Hey, if you want to push them up to 10, I'm here for it. But if we are trying to take the first step to level up, what we want to make sure is that we are asking our patients, how hard do you think this is? And some people are going to say it's hard because they're tired. Some people are going to say it's hard because of pain. or some people are going to say it's hard because it's effortful, and effort is the name of the game, right? Effort when we're bumping up against pain can be that we're kind of toggling in this wiggle room between this increase in pain and how long it takes for their pain to come down to baseline. It can be exertional effort, but effort is the currency that we are looking at when it comes to all of our rehab interventions. And so the step that I want you all to take is to take a rate of perceived exertion for every exercise. So if they are doing clams, if they are doing bed mobility, I wanna say how hard do you think that was on a scale of one to 10? Or was it easy, medium, or hard? And you want them at least in the medium. There are so many times where I think that I am hitting the right mark when it comes to intensity for my older adults, and then I ask them, and they're like, oh, it's like a three. And I was like, well, dang. Linda, I'm going to switch this weight for you." And we end up taking the weight and putting it higher. Of course, your clients learn that and they'll look at you and you'll ask and they'll say, eight. And I was like, I don't believe you. That's not an eight. And you switch that exercise out. But giving you a rating of perceived exertion, one, that's something that you can document to make sure that you're getting that intensity, is a great way for you to be able to level up your Jerry game today. Okay, I know I said three, but I'm gonna give you four. BEGIN TO MEASURE REST INTERVALS The fourth one that you can do, and then I'll kind of go through all of them again, is to record your rest. Oftentimes we do our sets and then we kind of wait and we wave a little bit and we think, oh, well, I'm getting bored or they're getting bored or they're finished with the story. Okay, we'll start the next set. And we have no idea what that intensity looks like if they are resting for 30 seconds versus 90. If you are working with an individual with a high enough amount of load, they should need that full minute to recover. And so if we don't Check how much rest they're getting it can be really difficult for us to know if we're hitting the mark again with intensity So I gave you a bonus one So I'll do three plus bonus that I didn't lie to you at the beginning of this session About or this podcast about what our ways for us to level up our Jerry game So let's bring this around full circle the first thing is I want to acknowledge you if the hardest part about leveling up your Jerry game is because of the mental state that you are in right now if that is because of your job if that is because of family stress if that has become because of work culture expectations that make it difficult. I want to first acknowledge that and where you are. And know that sometimes if you are sitting at a 40% baseline, your cognitive reserve, and you're giving 40%, then you're giving 100% of the effort that you have available right now. And I want that acknowledged. And I know that it's not just simple as like, let's just change these one things for individuals who are kind of in the throes of some of those difficulties. If you are able to get through and try one thing different today, I gave four options, right? So doing that AMRAP set, getting a person doing an exercise in standing that we probably would have biased towards sitting, taking a rating of perceived exertion for every exercise in a session, or measuring rest, putting a clock on in the background and having it roll up and just kind of getting an idea of how much rest individuals are taking. You'd be surprised how much of our exercises, our interventions are gone because of us taking longer rest intervals than are probably necessary. SUMMARY All right, if you want to learn more of these level up steps, you can hit us up at MMOA Live. In two weeks on the 17th, 18th, I'm in Oklahoma City, Oklahoma with Sam. It's going to be such a fun course. On the 23rd, 24th, We are in Gales Ferry, Connecticut. We actually also have a sold out course right now in Rochester on that same weekend, which is super exciting. I love when we see these big crowds. But Alex is going to be in Gales Ferry. And then March 2nd and 3rd, we are in Rome, Georgia and Sparks Glencoe, Maryland. So if you are looking to find us on the road, if you want to figure out all these level up techniques, That is the place to do it. It is two days. It is so fun. You get to hang out with us and our crew. Maybe we can give you that little boost of motivation that you need to take that first step forward. And we would love to be that little bit of a motivation boost and a culture for you if you are struggling right now with different aspects that are outside of your control and your patient's control. within our healthcare system. So I encourage you to see us on the road if you haven't yet. Have a wonderful rest of your week, everybody, and hopefully I will see you all eyeball to eyeball at a course soon. Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.