At the 2019 Combined Sections Meeting (CSM) in Washington, DC, Dr Carole B. Lewis was invited to give a “Distinguished Lecture” during the Academy's Recognition of Board-Certified Geriatric Clinical Specialists and Awards Ceremony. At the conclusion of the lecture on Academy of Geriatric Physical Therapy's President, Dr Greg Hartley, read the following resolution which was unanimously approved by the Board of Directors:
Resolution Establishing the Carole B. Lewis Lecture Award
Whereas, Dr Carole B. Lewis was a founding member of the Section on Geriatrics, now the Academy of Geriatric Physical Therapy;
Whereas, Dr Lewis was the 5th President of the Section on Geriatrics and laid the groundwork for development of numerous leaders in geriatric physical therapy;
Whereas, Dr Lewis has been teaching issues in geriatric physical therapy since 1984, including hundreds of lectures, academic classes, and including the 2016 Mary McMillan Lecture of the APTA;
Whereas, Dr Lewis was recognized as a Catherine Worthingham Fellow of the American Physical Therapy Association in 2006;
Whereas, Dr Lewis created the Journal, Topics in Geriatric Rehabilitation, in 1985 to disseminate research to improve the lives of older adults;
Whereas, during her presidency she was also in the first class of Geriatric Clinical Specialist, which now includes over 2400 Board-Certified Geriatric Clinical Specialists;
Whereas, Carole B. Lewis has served as an unofficial ambassador for positive aging and ending ageism; and,
Whereas, the Academy of Geriatric Physical Therapy is a better organization for the efforts of Dr Lewis in the areas of administration, education, patient care, research, and advocacy related to physical therapy for older adults; now, therefore, be it
Resolved, that the Academy of Geriatric Physical Therapy hereby creates the Carole B. Lewis Lecture Award to promote discussion of challenging issues, advocacy, and leadership in geriatric physical therapy. The lecture will be an annual event during the CSM of the APTA.
Adopted by the Academy of Geriatric Physical Therapy Board of Directors, this 29th day of May, 2018.
We are pleased to print the transcript of what will heretofore be known as the Carole B. Lewis Lecture, which will occur each year at CSM. Transcripts of all lectures provided by award recipients will be published in the Journal of Geriatric Physical Therapy.
GETTING TO GREAT IN GERIATRICS
Carole B. Lewis, PT, DPT, PhD, FSOAE, FAPTA
I would like to begin by thanking the Academy for the honor of giving the inaugural Distinguished Lecture Award. I am humbled, thrilled, and a little nervous. This presentation will be interactive, so take out your phone or a piece of paper and pen.
This morning's talk will cover 3 main areas that I believe can lead us to great geriatric physical therapy: improving quality, embracing the uniqueness of geriatrics, and planning for the future.
I have spent my career sifting through thousands of research studies, applying the most efficacious findings to my clinical practice, and then teaching what I've learned to others. Thus, my perspective on quality comes through this lens. Quality of evidence varies widely and it is incumbent upon us to become discriminating consumers. This ability begins in our professional education.
The rigor required to stay on top of the literature is demanding, but also rewarding, and the professors who provide this type of education set strong foundations for their students. However, it is easy to be lulled into complacency and to neglect updating course content or textbooks. Not updating wasn't much of a problem in the 1980s when textbooks were almost completely based on expert opinion, because for the most part, that was all we had. Today, physical therapy research is burgeoning and evidence of new and better forms of treatment is edging out earlier modalities. As the body of evidence proliferates, educators must not only teach content, but also critical thinking and how to evaluate quality of evidence. Every “fact” sited in a textbook must be substantiated by a reputable reference and faculty now encourage students to question the quality of evidence underlying all content.
The same scenario should occur in postprofessional education. Yet, I see substandard continuing education courses being offered almost everywhere. I recently received a small booklet worth 30 hours of CEUs approved by my licensing board.1 I flipped through the first article on Rotator Cuff Problems and found the information outdated. When I checked the references, there were only 3 from the last 5 years. Of the list of references below, which would you select to ensure you were getting current, reputable evidence-based information?
- Wikipedia (2016). Definitions. Retrieved September 17, 2016 from http://www.wikipedia.org/
- Rothstein, J., Roy, S., & Wolf, S. (2005) The Rehabilitation Specialist's Handbook. Philadelphia, PA: F.A. David Company.
- Chaconas EJ, Kolber MJ, Hanney WJ, Daugherty ML, Wilson SH, Sheets C. Shoulder external rotator eccentric training versus general shoulder exercise for subacromial pain syndrome: a randomized controlled trial. Int J Sports Phys Ther. 2017;12(7):1121-1133.
The first 2 were from the 30-hour course and the last 1 was from my shoulder lecture. I could not find a single current, reputable reference in the home study article. I was outraged! This is unacceptable. We must write to our boards (which I did) and let them know that if courses like this continue to be approved, we are making our therapists worse, not better.
So what can we do beyond being vigilant and willing to follow through with our boards? To be great, we must always question. “Where is the study for this?” “How strong is the evidence supporting this idea?”
And we must be cautious before embracing the shiny new toy. I know this is tough because sometimes I'm guilty of shiny new toy syndrome myself. I love new techniques, but before embracing them, we need to critically examine the evidence supporting them. I'd like to give you an example. Early in my career, Margaret Johnstone developed air splints that were designed to reduce or eliminate spasticity for persons with stroke. A therapist would apply the air splint in a very precise fashion, to a spastic arm for example, and while it was on, the spasticity looked pretty good. The shiny new toy was innovative and the promised results were exciting. Tens of thousands of dollars were spent on courses and on air splints. However, within minutes or maybe a half hour, the spasticity returned. The promised results never materialized. The air splints were not supported by credible evidence, they didn't work, and eventually they fell out of favor.
Another way to get to great is to institute a grand rounds program based on the protocol described by Dr Black.2 Once a month a therapist presents a patient case to a group of peers and the peers let loose and go all out trying to see if anything was missed. It can be a terrifying experience, but absolutely wonderful and much needed. It's needed because it fosters a mindset of constant questioning regarding what we do and what we can do better. It's a technique that can help us pierce the seduction of certainty. When I meet therapists who think they know it all or that their techniques and ideas are the best and must not be questioned, it makes me very uncomfortable. People who insist that they know it all are imposters. Great therapists aren't trying to “know it all” or even pretend to “know it all”; instead, they seek continual improvement. Many times I tell patients that I don't know the answer, but I will have an answer for them next time. Then I look it up and try to get the best information to them. None of us is perfect; we need to admit that and go on. So even if you're in a small practice, get together with a few of your colleagues once a month and have someone prepare a case. If there are 12 of you, you only need to put together a case once a year. It will build your knowledge base and improve critical thinking. You'll be surprised how valuable this can be. The Academy should consider having Grand Rounds as part of the programming at CSM.
Recognizing and incorporating quality takes effort. When you're in classes, take the time to evaluate the content and let others know if it's just flashy, cheap and easy, or if it's clinically relevant and based on solid evidence. We must support educators who are well prepared and passionate, otherwise the companies that provide substandard education will be allowed to flourish and the concerned and committed instructors will vanish.
A great way to keep up with current research and an easy way to check source material is through a free site called Amedeo.com. Once you sign up, you'll receive weekly updates on articles published in your specialization. You can paste the URL into your browser and it will take you to the PubMed abstract. This is incredibly easy. You don't have to read every article; as time permits, you can review the ones that relate directly to your area of interest.
A recent innovation undertaken by a large rehabilitation company is the use of researchers and knowledge brokers as clinical consultants. The consultants disseminate the most current and clinically relevant research findings and then the knowledge brokers assist clinicians to use the information in their practice. I see great potential in this approach to quality improvement and I eagerly await the results of this effort.
Finally, I encourage you to be excellent and unforgettable. I can remember getting great service from someone who fixed my car years ago because he went way out of his way to make sure everything was just right. I felt cared about and I will always go back there to service my car. He was unforgettable. Sometimes, perhaps because of all the paperwork, we find it difficult to look beyond the patient's knee or ankle issue to see the person who may be facing a balance problem very soon. When we look at the needs of the person and not just the specific problem listed in the paperwork, we demonstrate great care. The last thing we want is for one of our patients to say, “Why didn't someone tell me that my ankles had gotten stiff and could cause me to fall?”
So now it is your turn. Write down one piece of evidence you learned this week or one thing you will do next week that will improve the quality of your clinical practice.
Uniqueness of Geriatrics
There is so much that is unique about working with older persons. However, I believe that the areas having the greatest impact on providing the exceptional care are program duration and length, admitting a problem, and learning from our patients.
The literature in the past 2 decades has been very clear that older persons have a dose response to physical therapy. In other words, the more they get, the better their outcomes.3–5 Unfortunately, there is pressure to see our patients for less time, despite the fact that they would likely to do better with more time. Both Gomes-Osman et al6 and Sherrington et al7 found that a minimum of 50 hours is needed to get results with our interventions for cognition and balance improvement, respectively. Thus, we must find ways to make sure we are providing or designing and monitoring care for as long as our patients need it.
Older persons often don't like to admit they have a problem. Makris and colleagues' qualitative study8 of older persons with back pain found 3 themes, which I believe can be generalized to other issues such as balance deficits. Makris et al8 found that older adults didn't seek care for back pain because they thought it was the result of normal aging. They believed it was inevitable and there was nothing to be done about it. They also felt that other health problems were more important. In other word, pathologies like diabetes and heart problems were much more important than back pain or balance problems. The final reason for not seeking care was the belief that all they would receive would be medication and/or surgery and they didn't want that.
To me, this screams for the physical therapist in geriatrics to educate the community and physicians. Give talks at senior centers, physician offices, and medical meetings. Explain that back pain is not normal aging and that the first treatment option should be referral to physical therapy, not medication or surgery. If back pain is reduced or eliminated, patients can pursue physical activities that could improve their other pathologies such as diabetes or heart problems.
I urge you to commit to an educational activity once a month to help spread the word.
Lastly, I want to address learning from our patients, and this brings me to a story. When I first moved to DC, I took a job as the Director of the Arthritis Rehabilitation Center. I was hired to get it “up to snuff.” On my first day, I realized 6 of the 7 therapists were not licensed. So, my job was to fire 6 physical therapists. On the second day, I realized I had to treat the patients assigned to the 6 therapists that I had fired. The third patient to walk in that day is still one of the frailest patients I have ever treated. She was no taller than 4′8″ and weighed less than 80 lb. Her standard walker had more mass than she did. She walked right up to me and said “So you're the new therapist. I heard you fired everyone,” and she walked on. She got up on the table and said that she had received tremendous relief and was able to function for a week when the previous therapists had pulled her leg. I conducted a quick evaluation to see if that was a good idea and found that she had hip osteoarthritis and that a long-axis traction was a good treatment option. So, as she lay there in the supine position, I meticulously positioned her leg in the open, packed position, and grasped above her lateral and medial malleoli and gently pulled a couple times. As I was starting the third pull, she sat up with hands on her hips and said, “You look like a strong girl” and then she screamed, “Pull!” And she was right. That technique requires 100 N of force and because I was fearful it might be too much, I didn't do the technique correctly. I have heard therapist say that they learn so much about life from their patients, but listening can also help us to be better clinicians and is another step toward getting to great.
Your turn. Write down one thing you might do differently next week based on the uniqueness of geriatrics.
Planning for the Future
The delivery of care is changing. Where do we fit in? We need to look to a variety of ways to provide physical therapy in the future. One area crying out for the involvement of more physical therapists is prevention. In 2016, prevention was deemed to be important for the future of health care by both the World Health Organization and the National Academy of Medicine.9,10
Telehealth has already been shown to be effective in rehabilitation for persons who have balance issues, strokes, or total joint replacements.11–13 I think we can do more to prevent a host of problems by providing physical therapy via television or the Internet. What about a rehabilitation TV station or YouTube channel? In 2018, Bruns et al14 conducted a successful preventive exercise program with frail older adults who were planning to have colorectal surgery. I think this is just the beginning of incredible opportunities for physical therapy to make a difference in people's lives.
We need to get more involved in community outreach and the wellness market. Two excellent examples of these are from Denmark and the Netherlands. In the Netherlands, they have community exercise classes for balance. In 2018, this program was the subject of an impressive article in the New York Times. It consisted of providing community classes twice a week that include instruction in how to fall, practice in maneuvering obstacle courses, and home exercises. Many of us offer this type of training, but few of us reach out to the community to provide classes. I believe we have a role here and we should be providing community classes that are at least designed by a PT, and if possible, monitored or delivered by a PT as well. Instead of Gold's Gyms, we could have Old's Gyms with a plethora of classes designed specifically for older adults such as yoga, posture, flexibility, strength, tai chi, balance, endurance, pilates, and core. Older adults could come to our gyms and get 2 or 3 half day a week of specific exercises to keep them well.
The Good Life with osteoArthritis in Denmark (GLA:D) program has provided classes to over 30 000 older adults with knee osteoarthritis who were waiting for total joint surgery. The classes helped them stay safe while on wait lists and after surgery, and in some cases, patients found that they no longer needed surgery.15,16
The last area I want to address under planning for the future is the annual visit.17 I have been lobbying for this for decades. Just like glaucoma screenings, I believe that after age 50, routine visits to a physical therapist should be commonplace. If the evaluation doesn't reveal problem areas, another assessment wouldn't be due for 5 more years. If problems are discovered, patients should be referred for physical therapy and tested annually until the deficits have been corrected.
I developed the Adult Functional Independence Test (AFIT) specifically for the annual visit. It's not the only tool one can use, but it is a quick yet comprehensive assessment from head to toe that covers the areas of posture, flexibility, strength, balance, and endurance. What is wonderful about the AFIT is that all 15 of the tests use predictive analytics or national norms to calculate an individual's risk of disability, falls, fractures, and mortality. In addition, what is so cool is that there are evidence-based exercises we can give our patients to treat the deficits we find on the AFIT.18,19 To me, this is the future. I don't have a single patient who would prefer getting rehab after a hip fracture to avoiding the hip fracture in the first place. To serve our patients well, we need to move into the future with prevention and to do what it takes to get to great in geriatrics.
For your turn—look to your unique joys, gifts, and talents and design a job for yourself in 10 to 20 years based on how care is changing.
Are we getting to great? Incorporating quality? Embracing the uniqueness of geriatrics? Planning for the future?
Now it really is your turn.
—Carole B. Lewis, PT, DPT, PhD, FSOAE, FAPTA
1. Elite Learning. 2019 Physical Therapy Continuing Education. Ormond, FL: Elite Learning.
2. Black JD, Bauer KN, Spano GE, Voelkel SA, Palombaro KM. Grand rounds: a method for improving student learning and client care continuity in a student-run physical therapy pro bono clinic. JoSoTL. 2017;17(3):68–88.
3. Murray PK, Singer M, Dawson NV, Thomas CL, Cebul RD. Outcomes of rehabilitation services for nursing home residents. Arch Phys Med Rehabil. 2003;84(8):1129–1136.
4. Jette DU, Warren RL, Wirtalla C. The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Arch Phys Med Rehabil. 2005;86(3):373–379.
5. Peiris CL, Shields N, Brusco NK, Watts JJ, Taylor NF. Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and subacute conditions: an updated systematic review and meta-analysis. Arch Phys Med Rehabil. 2018;99(11):2299–2312.
6. Gomes-Osman J, Cabral DF, Morris TP, et al Exercise for cognitive brain health in aging: a systematic review for an evaluation of dose. Neurol Clin Pract. 2018;8(3):257–265.
7. Sherrington C, Michaleff ZA, Fairhall N, et al Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51(24):1750–1758.
8. Makris UE, Higashi RT, Marks EG, et al Ageism, negative attitudes, and competing co-morbidities—why older adults may not seek care for restricting back pain: a qualitative study. BMC Geriatr. 2015;15:39.
11. Chen J, Jin W, Dong WS, et al Effects of home-based tele-supervising rehabilitation on physical function for stroke survivors with hemiplegia: a randomized controlled trial. Am J Phys Med Rehabil, 2017;96(3):152–160.
12. Shukla H, Nair SR, Thakker D. Role of telerehabilitation in patients following total knee arthroplasty: evidence from a systematic literature review and meta-analysis. J Telemed Telecare, 2017;23(2):339–346.
13. Giordano A, Bonometti GP, Vanoglio F, et al Feasibility and cost-effectiveness of a multidisciplinary home-telehealth intervention programme to reduce falls among elderly discharged from hospital: study protocol for a randomized controlled trial. BMC Geriatr. 2016;16(1):209.
14. Bruns ERJ, Argillander TE, Schuijt HJ, et al Fit4SurgeryTV at-home pre-habilitation for frail elderly planned for colorectal cancer surgery: a pilot study [published online ahead of print December 13, 2018]. Am J Phys Med Rehabil. doi:10.1097/PHM.0000000000001108.
16. Skou ST, Roos EM. Good Life with osteoArthritis in Denmark (GLA:D™): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide. BMC Musculoskelet Disord. 2017;18(1):72.
17. Laflin M, Lewis C. Functional standards for optimal aging: the development of the moving target screen. Top Geriatr Rehabil. 2017;33(4):224–230.