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CAROLE B. LEWIS DISTINGUISHED LECTURE 2020

We Can Do Better: Aging and the Value of Physical Therapy

2020 Carole B. Lewis Distinguished Lecture: Address to the APTA Geriatrics Membership at the Combined Sections Meeting, Denver, CO, February 13, 2020

Avers, Dale PT, DPT, PhD, FAPTA

Journal of Geriatric Physical Therapy: July/September 2020 - Volume 43 - Issue 3 - p E31-E44
doi: 10.1519/JPT.0000000000000276
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I want to share a little story about an encounter I had recently. At the end of a meeting with my attorney, he told me his fiancé was a physical therapist, having graduated in 2016. He then asked me, “Do you think physical therapists will ever get the respect they deserve, and along with that the salary/payment?” Wow! He might as well asked me, “Do physical therapists provide value that is recognized or meaningful? What would you say?”

I'm passionate about the potential for our profession—as much now, after 40+ years as when I entered PT school. But have we realized our potential? I would say not. Do we demonstrate value? Not as consistently as we could. I have recently become aware of the reluctance of newly graduated and younger therapists not using their earned title Doctor. How many of you routinely use it as part of your patient care? And if you don't, can you say why? When I ask that question, the 2 most common reasons I hear is a lack of cultural support and that they don't want to appear to be better than those more experienced and who don't have their DPT. It seems our “blue” personalities—that part of us that doesn't like confrontation and wants everyone to feel good—may be getting in our way. And yet, we seem to have no issues with asserting our board certification. Why?

But I would also suggest that maybe any reluctance to fully embrace the title Doctor or any other credential is perhaps lower confidence in the potential of physical therapy. Do you practice in a way that demonstrates a passion and belief in the value of physical therapy, in a way that communicates that what you do really will make a difference?

What is value? The dictionary defines value as the importance, worth, or usefulness of something. It can also mean having a high opinion of something. The Centers for Medicare & Medicaid Services (CMS) defines value-based care as care linked to outcomes and reflective of the patient's experience of care.1 Do we have personal confidence that physical therapy in general or our individual care specifically provides value? Perhaps many of you feel like you are still growing into your Doctor title and not wholly confident of the value physical therapy can provide to our patients and to society. That is what I want to talk about today.

But first, let me say it is one of my greatest honors to be chosen as the second Carole B. Lewis Distinguished Lecturer for the Academy of Geriatric Physical Therapy. I thank the Academy's leadership for having the faith in me that I will deliver a meaningful lecture (we'll see!). I'd like to acknowledge the many students, educators, and clinicians with which I've had the privilege to teach and interact. I would not be here today without your encouragement and support. And I especially want to thank some folks that have had a special significance on my professional life. Without question, Dr Carole Lewis has been one of my most influential mentors. We started in the Academy within a couple of years of each other and so I got to know her very early on in the Academy's history. She brought enthusiasm and passion to her teaching and her positivity to improve the lives of older adults resonated with me. She was such a natural, charismatic leader (some of you will remember the hats) that I felt compelled to follow her. She passionately and expertly shared evidence that focused the practice of physical therapy on what could really make a difference to the individual. Thank you, Carole, for providing the example and inspiration for me and for so many others to serve older adults with excellence and pride.

I would also like to thank 3 other influential mentors—Rita Wong, Marybeth Brown and Andrew Guccione. They have taught me so much, from our first meeting writing questions for the first Geriatric Certified Specialist (GCS) examination to collaborating on 2 editions of 2 books. They are all great models of aging and their friendship means everything to me.

However, the person who inspires me the most is my mother, who has given me the great honor of being with me here, this morning. My mother is a kind, intelligent, and gifted educator and leader and I'm proud to be her daughter. She is also a terrific example of exemplary aging. Ironically, her inspiration for how she is aging comes from how she didn't want to age. Her mother, my grandmother, was not a fan of physical activity. As a consequence, although she lived to be almost 100, she was bed ridden the last years of her life. Mom was determined to age differently—and indeed she has. Starting with walking in the mall during her 60s and transitioning to using a treadmill (for weather reasons) around the age of 80, she has engaged in daily physical exercise. She walks on her treadmill at a pace of 4.8 mph for 30 minutes (that's a pace of 1.79 m/s) and engages in body-weight strengthening holding a plank for 2 minutes, performing lunges better than I do, achieving 15 sit-to-stands in 30 seconds, and now includes triceps dips, half Turkish get-ups, and push-ups. This is at the age of 89.5 years! She also teaches an exercise class! My biggest issue is she has set the bar so high, it is making my aging more difficult! Mom, I love you and admire you so much. Please stand up and be recognized.

This is undoubtedly the most daunting talk I've ever done ... to deliver a 90-minute (for the record, 90 minutes was not my idea, but true to my nature, I've filled every minute of it) lecture that shares a bit of my journey and then something profound enough to change/nudge/stimulate your own journey. But let me begin. My earliest view of aging was influenced by my grandparents—who fortunately, were all healthy well into their very old age. Growing up, I didn't see disability or decline, and I think this helped me avoid a fear or distaste for older people. Geriatric physical therapy wasn't something you “went into” when I was in physical therapy school at the University of Kentucky. But my first job was in a nursing home, albeit unintentionally. However, I learned so much there, working as the only therapist, and under a visionary nursing home administrator. But it didn't take long to recognize there wasn't much joy in the place, in spite of the efforts being made—and we spent a lot of time talking about reasons for the climate of long-term care. I even got my nursing home administrator's license thinking that might be a pathway of changing the culture. I think the question that started at that first job, and has stayed with me, is “why are these people here? No one seemed to want to be here, so what happened?” That basic question has driven my professional practice. I wanted to help older individuals avoid nursing homes, and to educate physical therapists and students to have higher expectations than “dragging someone down the hall” (now we push them on their rolling walkers).

Then, after 15 years of clinical practice, I was encouraged to have more influence on other therapists and turned a corner into academia where my goal has been to change practice for the better. I suppose the goal of changing practice for the better is similar to my desire to facilitate successful aging for every aging adult. But what is successful aging? It is a complex topic with no clear definition and a lot of critics rightfully poke holes into any definition. So, to avoid that controversy, I'm going to use the term “intentional aging.” Intentional aging is deliberate, of making decisions about how one wants to age, of adapting in positive ways to the changes aging brings. Yet, so many older folks are passive about their aging. I think the opportunity for us to engage in a proactive approach to facilitate and support intentional aging is immense and I want to share some ideas about how physical therapists can do that. I also want to share a bit about shifting paradigms of practice, which can enhance or undermine intentional aging. And then, finally, I'm going to talk about a few things, ok, it might be more than a few things, that we can do better, that can make our practice better, and that demonstrates the value of our profession.

The objectives for this lecture are:

Following your active attention in this lecture, you will be able to:

  1. Reflect on the value of physical therapy for older adults
  2. Recognize the consequences of implicit bias in the physical therapy delivery of older adults
  3. Recognize the implications of common models of aging on the delivery of care on chronic disease management and intentional aging
  4. Gain awareness of societal approaches to aging that are enhanced with physical therapy
  5. Reflect on proposed standards for the provision of geriatric physical therapy
  6. Have a benchmark to self-assess your delivery of care

PARADIGMS OF AGING

We have an image program in geriatrics. That image is too often the perspective of decline and decay as aging. Most of us are aware of the often negative reaction generated when aging is mentioned. For fun, I made a list of all the words used to describe aging that began with D. Just look at them (Figure 1)!

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Figure 1.:
Decline and Decay Model: The D's of Aging.

Aging is often used as an excuse, “I'm just getting old” or as a negative prophesy, “I won't be able to do stairs someday.” As an active physical therapist, I am frequently struck by these views, as if they have nothing to do with the outcome. Aging seems to be something folks let happen, without a lot of thought. Yet, most of the health problems of older age are exacerbated by inactivity and deconditioning, intentional factors. In fact, depending on the source, 60% to 70% of a person's health is due to factors we can influence, if not control, such as social, behavioral, and environmental factors at any age. That means the decisions we make (whether they are active or inactive decisions) have enormous influence on our health especially in how the fourth age of our lives will look, when the end of life is near, says geriatrician Louise Aronson in her book Elderhood.2

I love visiting my mom at her retirement living complex—for lots of reasons, but especially because of all I learn. We have the best talks about aging and how and why different people age. Aging has so many faces, so many presentations, and I can't help but wonder what accounts for the differences. The more I spend time as a visitor, the more I believe aging intentionally comes down to attitude. An attitude of perseverance or an attitude of giving in and giving up. My mother shared an insight that perhaps the folks we see in assisted living and retirement centers who seem to be aging passively and becoming frail expend the effort and work, such as exercising and being physically active, that was necessary to stay in their homes; but then an event happens, a spouse dies, an illness occurs that makes it impossible to stay ... and they make the huge transition to a more “protected” lifestyle that reflects the acceptance of gradual and increasing dependency. This acceptance often includes a largely sedentary existence and rarely includes exercise. Her insight aligns with the lived experience of elders that indicates as long as they are actively engaged in the process of living, of fighting against the desire to give up and give in, they do not believe they are frail, despite any physical characterizations.3 If this is so, it means as physical therapists, we need to adjust expectations to make sure they are reflective of the older person's expectations, and that we enhance their capacity where they choose to be. The adaptation to some form of dependency also means we need to encourage the building of reserve in the third age—in the 50s, 60s, and 70's to prepare and support the fourth age when the physical and cognitive reflections of age become more obvious. Much of how we age is a choice, is intentional. Living intentionally, and having purpose, whether its engaging in exercise, socialization, volunteerism, projects, business etc., or as may be for some ..., adapting to limitations in capacity; seems to be the critical factor in aging successfully. I am impressed with how my mother and several of her friends take care of each other, help each other, growing in their interdependency as they adapt to reduced eyesight, limited mobility, and declining memory. Their adaptations are intentional, and physical therapists impact this through our focus on function and mobility.

Good health is the great enabler of a long, happy, and meaningful life.4 Without it we lack the energy and drive to pursue happiness, to carry out our daily roles and responsibilities, to work and volunteer, to engage in meaningful relationships, and to stay engaged in society. Yet unhealthy behaviors remain prevalent among older people, and health systems are poorly aligned with the needs of older populations who have multiple chronic diseases. Individually and societally, we seem to be ignoring the opportunity to positively influence our own aging and the health of our aging clients. Instead medicine seems to operate from a mechanistic model: fixing and replacing parts at will in single episodes of care, without a thought to the context of the patient's remaining life or even continuum of care. Too often the focus is on treating age as a disease, as something to be fixed rather than how to improve capacity within the context of multiple chronic diseases.

But aging can't be fixed, can it? And replacing a body part, say a knee or hip, doesn't mean the body will be as good as new. So how do we as physical therapists avoid the trap of the mechanistic model, the inclination to “fix” things rather than manage them? In short, how do we build capacity in the third and fourth stages of life?

Ageism is seen in the traditional expectations of how we are to live our older years. Do we regard a 75-year-old as “special” or “usual” if she actively exercises, hasn't withdrawn, slowed down, or otherwise become diminished? If the added years science and technology have given us are spent in good health, people's ability to do the things they value, that matter the most, will have few limits. However, if these added years are dominated by declines in physical and mental capacities, the implications for older people and for society may be much more negative. Jo Ann Jenkins, the CEO of AARP, discusses the opportunities that come with longevity in her book Disrupt Aging.4 She suggests the gift of increased longevity presents possibilities of fulfillment, legacy, and health. She believes the majority of older people approaching traditional retirement age, say the third age, do not actually want to retire in the traditional sense. Rather, they want to remain active participants in society, even continuing to work in some capacity. Combining good health and function by building capacity and disrupting the decline and decay perspective of aging may allow greater and prolonged productivity, either in the workforce, volunteer activities, in one's family, etc, and thus benefit the individual and society. Physical therapists help folks live these extra years with purpose and adequate functional mobility, expanding the active years and compressing and lessening dependency. This is value.

We must also check our paternalism and low expectations that we may implicitly communicate. Why do we ask “are you tired” or if a person needs a rest when we are taught how to observe and measure physiologic and motor signs of fatigue? And what about our expectations for strength? Do we know what the average amount of weight an individual over 65 should leg press? Do we even have access to a leg press? Or do we make excuses? In short, do we expect that our older patients/clients have the capacity to be strong, steady, active, and participating adults? I still get reasons from therapists for not using high-intensity strengthening for patients/clients of “too fragile, unwilling, or too old.” Indeed there may be some unwillingness on the part of patients—but that's the challenge in front of us, because we know the evidence. It is still too common to see therapists start with a minimalist goal of returning the patient to their prior level of functioning when that prior level in all likelihood precipitated the current health care crisis. Other ways we implicitly demonstrate aging bias is prescribing a walker for balance instead of poles to compensate for balance issues or having the expectation of diminishment.

We have a challenge in that we interact with a diverse group of elders with differing needs and abilities. We may have individuals who are seeing nothing but possibilities in their retirement and want as much physical capacity as possible and we see folks edging toward the end of their life. That means we must reset our expectations every time we see a different patient. Any reduced expectations limit our capacity to help our patients age and function to their desired capacity level. Reduced expectations also feed into or reinforce the low expectations an older person may have for their own aging. Low expectations for the aging process and for the capacity-building of older people has no place in communicating the value of what we do and what we have to offer aging adults. This is a good time to reflect on how you want your own aging to be, to explore your personal expectations—and then do something that will achieve them! I am pleased that the Academy of Geriatric Physical Therapy has been exploring the need to change the old paradigm and pursue a future that embraces and seeks opportunities to communicate and deliver value through physical therapy services. For the better part of the year, they have been working on a total rebranding that is quite visionary—and the unveiling happens tonight. I can't wait to see and hear!

SOCIETAL AGING PARADIGMS

At a societal level, there is a lot of interest in developing new aging paradigms that are more appropriate for the increased longevity being experienced and for the presence of chronic diseases that need to be managed, rather than fixed. These models emphasize goals of active engagement and empowerment, in short, capacity building. Each of these models implicates the role of physical therapy, and offers us an opportunity to demonstrate our value.

Let's take a look at 3.

The Healthy Aging in Action model of the National Preventative Council5 addresses the policies that are needed to advance a healthy aging paradigm. Their goal is to advance healthy aging. Healthy aging is defined as the promotion of health, prevention of injury, and management of chronic diseases; of optimizing physical, cognitive, and mental health; and of facilitating social engagement. I like the way the National Prevention Council states the challenge: “We need to create a culture where older adults are viewed as vibrant, important, and productive members of society.” One of the premises of the National Aging in Action model is that most Americans want to live independently and remain in their own homes and chosen communities as they grow older. Some of the initiatives that are related to physical therapy include:

  • provide information about healthy options,
  • support and empower informal caregivers to promote healthy aging,
  • increase access to preventative services,
  • develop fall prevention programs,
  • train physicians and others health care professionals on age-related health issues, and
  • expand the availability of home and community-based services.

For example, helping folks age in place is a way physical therapists demonstrate value to society and to patients and their caregivers and families. Another goal is to expand fall prevention programs. As physical therapists, we should be leading in this area, implementing best practices in community-based fall prevention efforts while increasing access to those programs. The National Prevention Council model includes many other goals that implicate physical therapy that we would do well to formally address and that would promote our value.

The World Health Organization's (WHO's) Active Aging Framework6 is the second model I share with you because of the integral role of physical therapy. The WHO has defined healthy aging as the process of developing and maintaining the functional ability that enables well-being in older age. They have gathered energy and purpose around healthy aging to ensure that “older persons remain a resource to their families, communities and economies.” A focus of their Framework is promoting social engagement. And since there is a strong relationship between social engagement and mobility, social engagement may be a way of measuring physical therapy value. If someone cannot mobilize outdoors, and cannot negotiate transportation, then the risk for social isolation occurs, and frailty can result. Physical therapy is integral to the WHO's Active Aging Framework of healthy aging.

The 4Ms Framework is the third and last model I want to share. It is aimed at the challenges that the sequela of chronic conditions presents, especially in the acute care setting. The John A. Hartford Foundation and others recognized that older people suffer a disproportionate share of harm because of the lack of recognition of the consequences of chronic diseases. They have created a social movement whereby all care for older adults is age-friendly care. Age-friendly care is defined as following evidence-based practices, causing no harm, and aligning with What Matters to the older adult and their family caregivers. The evidence-based elements of high-quality care are called the 4Ms. The 4Ms are What Matters, Medications, Mentation, and Mobility. I don't know about you but I see physical therapy all through this model, so let me elaborate a bit.

What Matters to the patient is about truly knowing the person's desires, hopes, and dreams. Ideally, this is documented from the beginning at the Welcome to Medicare visit or any annual wellness visit, so the entire team is aware of what is important to the individual and can deliver care in concert with these desires. The focus on Medications advocates for the judicious use of medications so that they don't interfere with what matters to the older adult or mentation across the settings of care. Mentation involves the active management of dementia, depression, and delirium across all the settings of care. And the fourth, Mobility ensures that older adults move safely every day to maintain their function and to achieve what matters to the person. It involves regular and ongoing mobility screening. The 4Ms are so integral to inpatient therapy that we must be advocates for the model, encouraging its use in our hospitals.

So there we have 3 exciting models that address the complexity of aging from a variety of perspectives—but that all implicate the value of physical therapy. Even the surgeons have recognized the need to “do better” by our older folks. The American College of Surgeons has developed the Geriatric Surgery Verification7 that presents 30 new surgical standards designed to systematically improve surgical care and outcomes for the aging adult population. The standards outline a process for systematically improving older adult surgical care (Figure 2).

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Figure 2.:
American College of Surgeons Geriatric Surgery Verification Standards.

EXEMPLARS FOR GERIATRIC PHYSICAL THERAPY PRACTICE

I believe the physical therapy profession can do better by our aging folks as well. And perhaps our own set of standards or exemplars will help. Let me say I enthusiastically applaud the Academy's efforts to recognize geriatric physical therapists as the exercise experts for older adults. With the excellent CEEAA course and its new partner, the Advanced CEEAA, physical therapists have a valid way of obtaining the knowledge and skills required to expertly deliver our most important intervention, exercise! I understand the Academy is launching a fall prevention certification. I also applaud the Academy's support of research—which we've done for over 40 years. The Academy is advancing the knowledge of evidence to inform best practices in geriatric physical therapy, the noblest of efforts. It is also advancing an initiative of creating academic standards for geriatric education following the example of the Academy of Neurological Physical Therapy. And, in 2011 the Academy of Geriatric Physical Therapy approved a list of competencies in the care of older adults for entry-level physical therapists.8 But this document is now nearly 10 years old. It deserves to be reviewed and updated within the contexts of the models I've just presented and from the perspective of adding value to physical therapy practice.

One of our greatest limitations in this marvelous profession of ours is the variability of physical therapy care, which can negatively affect our value. There is no way for the public to know how to determine the quality or how to identify a high-quality geriatric physical therapist, or even what to expect. In other words, our value is hiding under a bushel basket. In part, this is because we don't have a unifying approach or paradigm to aging—some of us have adopted the mechanistic model of fixing,9 perhaps creating fear while we are doing it by using phrases like, “bone-on-bone,” “stop when you feel pain,” and “slow down”; while others have embraced the building capacity model by encouraging patients to do more and facilitating adaptation. Building capacity means promoting and strengthening one's abilities, which may mean providing the skills to adapt to retain abilities based on the individual's expectations and desires for function, activity, and participation, regardless of setting. I believe the building capacity model directly relates to older adults' self-perceptions and is the model that provides the most value to society. But to achieve this value, we need some consistency of practice. Therefore, I believe we need to establish a set of exemplars or standards that are informed by evidence, the models I've just described (the Healthy Aging Initiative, WHO, the 4Ms Framework), and of course the vision of the Academy. And once these exemplars are established, they need to be integrated into every entry-level program. They also could be used as benchmarks by physical therapists throughout their professional practice lives. Remember the APTA list of 5 interventions that consumers should avoid? The second one was avoiding underdosing of strength programs for older adults. While these 5 interventions form the basis of APTA's Choosing Wisely Campaign—-they are stated in the negative and don't help consumers know what to look for. The Academy can be bolder in setting forth our own lists of exemplars or standards as guidelines for the physical therapy care of older adults and publicized as a way of demonstrating our value. The Academy of Neurologic Physical Therapy has done this through their Clinical Practice Guidelines and may be a useful model for us.

Exemplars can inform quality benchmarks that quantify our value and promote consistency of practice. With these exemplars, consumers can shop for effective practitioners and know what to expect from a physical therapist. Exemplars can be used by educational institutions to inform the geriatric content in the curriculum. The continuum of care, that is all settings, should reflect these exemplars. The bar needs to be high. It's the only way we are going to grow and mature as a specialty area, to meet the diverse needs of the country's older adults and thus to demonstrate our value.

To that end, I'd like to share my ideas for exemplars. This list is meant to be a starting point for discussion and debate. I encourage you to think about what you believe are quality indicators that will demonstrate our value to society. When this lecture is published, there will be a mechanism for you to share your ideas and thoughts. Regardless of our agreement, we need to be fearless about offending those less passionate and not get stuck in perfectionism. These exemplars can help us boldly proclaim all we have to offer, that is to demonstrate our value. We must do better. We can do better. Ready?

My proposed 5 exemplars are that the physical therapist working with older adults:

  1. Possess an expertise about the aging process and geriatric physical therapy that is continually modified, reflected upon, and shared.
  2. Practice person-centered care within a capacity-building paradigm.
  3. Conduct a comprehensive evaluation that is informed by meaningful outcome measures and screens for vulnerabilities.
  4. Perform best practice and evidence-based interventions implemented with creativity, appropriate challenge, and relevance, which empowers and achieves what matters the most to the patient, and
  5. Advocate for the role of physical therapy to promote intentional aging across the continuum of care.

Allow me to elaborate on each of these proposed exemplars that could be used to inform best practices for older adults.

First, the geriatric physical therapists possess an expertise about the aging process and geriatric physical therapy that is continually modified, reflected upon, and shared. To help build the foundation for this expertise, I believe all physical therapist education curriculums should have substantial aging content that is based on best practices. I believe the profession as a whole will benefit from a standardized geriatric curriculum that is grounded in the current evidence and in best practices. And we can also do a better job in implementing the evidence for how educational practices can reduce ageism. In a systematic review of educational interventions for students, 88% of the studies successfully reduced ageism.10 Perhaps a continuing education course is needed in how to effectively teach geriatrics. It so irks me that a unique course in geriatrics is not required by the Commission on Accreditation in Physical Therapy Education (CAPTE) (unlike pediatrics) in spite of nearly half of all patients in acute and outpatient settings being older adults. Without an expert in aging teaching geriatric content or guiding an integrated approach, the “same old-same old” way of thinking (decline and decay) can be communicated throughout the curriculum. What if the person that is teaching students how to care for older adults isn't current in effective dosing for optimal strength gains, or worse, hasn't examined his or her own aging biases? Perhaps one of the reasons we see less informed therapists underdosing older adults is because this is how they've been taught. Educational programs should be preparing their graduates to be adept at implementing the evidence on effective exercise. Even though the restrictions the CMS has placed on the education of physical therapist students make clinical education difficult, we must continue to promote active aging and how to build capacity to demonstrate our value. This means finding creative ways to have students engage with a variety of older adults. For example, in my geriatrics course, students treat participants in a medical and social day care program. This experience allows students to manage the many facets of chronic diseases. Meanwhile, we have to continue to lobby for appropriate training and reimbursement models. But we can't wait for those models to be supportive of our profession. We must take the lead and move forward despite these barriers. It is the right thing to do and I am hopeful there is opportunity in the new reimbursement emphasis on value.

In addition to promoting best practices in academic settings to build clinical expertise, I'd like to propose the development of Geriatric Fellowships across specialty areas. Geriatric clinical practice is complex and requires a mastery of many other specialty areas such as cardiopulmonary, orthopedics, and neurology. To be a competent geriatric practitioner, you need to have expertise in orthopedics and be a skilled manual therapist, you need to be adept in cardiopulmonary and neurological content and clinical conditions, you need to master the complexities of many different diverse settings that are specialties in of themselves ... in other words ... geriatrics is a multifaceted and complex specialty area. And this complexity may be one of the reasons new therapists are not embracing geriatric clinical residencies, as it may appear more manageable to focus on neuro or ortho as a content area. And perhaps it makes sense to master one content area before tackling the complexity of geriatrics. Since the vast majority of physical therapy settings don't have a GCS, much less a CEEAA, in spite of serving older adults, offering fellowships for specialists in areas such as orthopedics, acute care, and community health, similar to how medicine offers geriatric fellowships in internal medicine and family practice; may be a way of promoting best practices and achieving our own version of age-friendly care. I believe we have a responsibility to provide a knowledge base for physical therapists who don't consider themselves primarily geriatric physical therapists, who have a specialization in another area, to engage them in geriatric best practices. I would encourage the Academy to be an innovator in promoting and achieving cross-specialty fellowships.

We also need to have expectations for updating our knowledge. For example, I began teaching functional assessment 25 years ago. I thought it was the greatest thing since sliced bread. Finally, we had an objective way to measure fall risk and other mobility issues. The potentials seemed endless and I was a fierce champion of objectivity of fall risk. Remember, this was before we knew what contributed to fall risk. But with time, the research showed us that no tool was better at predicting fall risk than our own clinical judgment. The prognostic accuracy of the tools just wasn't there. Additionally, the fall risk tools were not designed to be interpreted as a dichotomy—yes fall risk, no fall risk.

We need to appreciate that every older adult is at fall risk, by virtue of their age and often their fall history. Just because someone is scored a 52 on a Berg Balance Test does not mean they are not at fall risk! Just because a therapist learned once upon a time, perhaps in school or in a continuing education course that I may have taught some time ago, that a 48 on a Berg was a cut-off score for fall risk, does not make it true now. Research evolves, thank goodness. And now we know, from the authors, that the Berg was never designed to be used as a single fall risk tool and certainly not to be scored dichotomously. Furthermore a recent article11 found the Berg is not challenging for community-dwelling seniors, and yet it is one of the most often used tools in the clinic. And these issues are applicable for every tool we use. Commissioned by the Academy, Michelle Lusardi and her team12 wrote an elegant article about the performance of fall risk tools. After extensive analysis, they found that no tool was suitable by itself to determine fall risk. Rather, they found a cluster of tools performed better in predicting fall risk, much like you see in orthopedics to determine the presence of a rotator cuff tear.

Every therapist must be committed to keeping current in their practice areas. Because I can tell you, no matter how current the evidence is that I teach to entry-level students, what carries the most weight is what the students see and learn in the clinic. They tell me, “But my CI used the Berg for fall risk.” Or they go into clinic armed with the most recent knowledge, and have it rejected by the clinical instructor (CI) because it differs from what the CI learned once upon a time. How will we ever advance practice if we don't value keeping current and accept that knowledge evolves?

In the October-December issue of the Journal of Geriatric Physical Therapy, Editor Leslie Allison13 quoted a chilling commentary paper titled, “Does anyone read medical journals anymore?” Physicians attending a professional meeting were asked about reading professional literature by a hand raise. Shockingly, none admitted to reading a scientific journal, article, or paper. Are physical therapists any different? While a majority of us believe in the value of evidence-based practice, do we read with regularity, stay current in our areas, and then implement what we read? I know keeping current is difficult for busy clinicians. But there are ways that one can do this with just a little effort and time, such as having NCBI's PubMed push individualized searches to you once/month that reflect topics you care about, such as outcome measures. You can easily scan the titles for relevance and read abstracts. GeriNotes or the Journal of Geriatric Physical Therapy could have a regular column on an evidence update. The Academy could provide links to these sorts of searches that you could easily tap into. The expectation should be that we have a professional obligation to stay current because evidence is dynamic, and our understandings evolve.

Perhaps it's time to explore a feasible relicensing examination that emphasizes content of the past 10 years. If you are board certified, you wouldn't have to take the currency examination. It really is an injustice to physical therapy consumers that a therapist licensed some 40 years ago can still practice the way they were taught or reenter the clinical workforce without any updating, save what might be required by their state's licensure requirements. I don't believe this is fair to consumers of physical therapy nor to the profession. Most people who completed a TDPT program recognize how much had changed. We must take steps to require currency of all therapists, and we as an Academy have a particular interest in this because so many nongeriatric therapists care for older adults. The Academy can contribute the geriatric knowledge that is essential for practicing clinicians across all settings.

And once our knowledge is current and informed, we have an obligation to share it with our patients in a supportive and affirming manner. We can do better about affirming the power of our interventions. We are the masters of the most effective and powerful interventions, exercise, and manual therapy, which are particularly relevant to older adults. We must advocate for these interventions through their effective use, thus advocating for our value. And we should share this evidence with referral sources, third-party payers, students, as well as patients and caregivers. We must defend and rigorously advocate for best practices and not be afraid of denials. When we defend our practice decisions with evidence and passion, adverse rulings get over turned, like when Fox Rehab fought the OIG over the denial of $30 million of patient care based on arbitrary and inconsistent reviews. However, they stuck to their guns, knew the regulations, provided the evidence for their practice decisions, and won. It wasn't easy, and was expensive, but the point is that when you are practicing with evidence, you are going to be on solid ground.

Our responsibility is to stay current, to challenge our beliefs and knowledge, and to embrace change. We can do better. And what does possession of the expertise about the aging process that is continually modified, reflected upon, and shared look like to outsiders? It looks like a physical therapist that is focused on the concerns of the patient well-versed in the evidence with a humility to recognize the limitations of the evidence, and a passion to advocate for the potential of physical therapy to improve the well-being of the patient throughout their aging process.

The second exemplar is that of practicing person-centered care within a capacity-building paradigm.

The concept of having the person be the driving force in their health care decisions is considered the gold standard for health care, worldwide.14 Note the use of the word person rather than patient, thus validating the temporary role of the patient while emphasizing person-hood as the broader context of interactions. Person-centered care means that an individual's values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals.14 It is achieved through a dynamic relationship with the therapist, “patient,” and others who are important to the patient. The way the patient reacts to physiological responses is what makes the patient so very unique, and sometimes frustrating, if not baffling at times! To ignore the patient's psychosocial response is to reduce the patient to symptoms or to a disease, reverting to the mechanistic model of care.

Person-centered care requires humility because unless we are gifted with still delivering physical therapy at age 85, we must remember we don't know how it feels to be 85 yet! We need to be cognizant that our older patient/clients are living something we haven't experienced. Let me share an example. My mother's closest friend, lives in the same independent living residence as my mother and is 98. She is like an energizer bunny ... always going, always in charge, knows everything that is going on and knows everybody. She is amazing. But one time I asked her, what do you notice at 98, about your own body, that wasn't apparent 10 to 20 years ago? She said, “Sometimes I have to make myself get out of bed in the mornings. It's like my body just wants to lie there.” I was so surprised, because she rarely sits down, her days are full of activities. We just don't know how it feels! So here is a challenge to you: Do we listen with an attitude of learning? An aspect of cultural humility is being vulnerable, admitting we don't know how it feels to be their age, that we are continuous learners about what it means to be older, even really old!

Person-centered goal setting is central to person-centered care and should be considered best practices. Individual goal setting is an important way of demonstrating person-centered care. We demonstrate person-centered care when we ask in a genuine way “what are your concerns” and actively listen to the response, probing deeper into generalized comments like “I'm afraid I won't be able to go home.” The responses elicited provide us with specific tasks that will be meaningful to the patient.

I'm not pretending person-centered goal setting is easy. Many patients have such low or repressed expectations, it may be several sessions before they state a genuine, specific desire. But there are techniques espoused by Tripicchio and others15 that are effective in eliciting what matters the most from even the most apathetic person. I remember seeing a patient in Singapore at the request of the therapists because he was not making progress in therapy and was quite apathetic. And all I did was ask him about what he loved to do before his stroke and what he wanted to do again. He said hiking! So I asked him what he thought he would have to do to realize his desire. He said walk! So I asked him how much, he said “a lot.” And then I asked him when he wanted to get started. And he said now! And proceeded to walk, with relatively little assistance 4 times farther than he had walked previously. All because he was allowed to direct his therapy. Now he may never achieve his goal, but he will try, the therapists will try, and adaptations will occur. We can do better.

The Enhancing Medical Rehabilitation (EMR) model16 uses person-centered care at its core and has demonstrated evidence of effectiveness. Because it addresses some of the problems I've already touched on, I'd like to share it with you. It has 3 elements17 shown in Figure 3.

F3
Figure 3.:
Permission granted by author (Eric Lenze). Enhanced Medical Rehabilitation Model.

The first element is the patient is boss. This means the therapist practices optimal communication, resists taking over the session, thus allowing the patient to be in control, and continually looks for opportunities to ask for the patient's input. The hallmark of this principle is, “Ask, Ask, Ask.” Avoid telling and ask instead. Regard the patient as the boss while developing your role as therapist-coach to facilitating empowerment. Paternalism can be avoided when you make the patient the boss.

The second element is linking activities to personal goals. This principle is making goals from what matters the most to the patient. I especially like a strategy used in the EMR model of taking pictures of specific places in the person's home that might be challenging to navigate, such as a narrow hallway or small bathroom. The pictures provide highly personal, visual representation of challenges to address. With these pictures, the patient describes the mobility problem, prompting the patient and the therapist to work together to solve the challenge. This is a simple strategy of personalizing the treatment session, utilizing task specificity in our interventions, with the added advantage of showing the patient we are focused on their goal.

The third element is optimizing intensity. This element is based on the principle that an engaged patient that is focused on what matters the most is better prepared for higher-intensity therapy. It is about designing challenging, intense activities that elicit maximum effort and full physical and cognitive engagement while making the connection to the goals. The aim is to minimize rests only unless they are patient-initiated and to keep the patient physically engaged in therapy at least 65% of the session. Our job is to maximize capacity of our older patient to achieve the patient's vision for him/herself. A model like this can help.

In summary, what does the practice of person-centered care look like to an older adult? The patient experiences genuine caring through the therapist's focus on the patient, feels genuinely listened to, feels like a partner in their individualized care, and feels empowered to learn self-management of their aging process. And because the patient's experience of therapy is different than outcomes, but required by the CMS, specific tools measuring the older adult's experience are needed.

My third proposed exemplar is about conducting our initial encounter. Every therapist interacting with an older adult should conduct a relatively standardized evaluation that is informed by meaningful outcome measures (ie, focused on function) and includes screening for vulnerabilities.

Let me explain.

Physical therapists are extraordinarily positioned to identify mobility problems and the geriatric syndromes of sarcopenia, falls, urinary incontinence, frailty, and acute cognitive decline. We can identify the risk for disability and care dependency better than anyone. And this ability is value-laden when we can identify problems before they become significant issues.

We need to standardize our initial patient encounters. This should begin with key questions across all settings. Asking about a medication history is a CMS quality indicator but being aware of the effects of problematic drugs is a required skill of any physical therapist working with older adults. Taking a fall history is another CMS indicator. Drilling into the mechanism of the fall will help determine the likelihood of vestibular, visual, or strength/nervous system contributions and thus drive the examination. Asking about a physical activity history drills into a core issue of so many functional mobility problems and must be addressed to affect the best outcomes. And my fourth mandatory question across all settings is also a CMS quality indicator, Do you have any functional problems? This can be focused on mobility such as “can you walk at least a ¼ mile,” “climb stairs,” and “get up from the floor”? The inability to get up off the floor is one of the earliest indicators of mobility disability and reasons to call 911 and should be asked in all outpatient and home health settings. Other questions that get at the comprehensiveness of older adults can be added, depending on your setting, expertise, time, etc, but I believe these are important enough that they should be required within every initial encounter.

Using the best outcome measures that assess and measure function and mobility in a standard way is how we collect data to demonstrate our value. Alan Jette18 advocated for a minimum set of functional outcomes that have the rigor to demonstrate valid outcomes that matter to the patient and the CMS is leaving to us which outcome measures will best reflect our value. As optimistic as I am about CMS's focus on value, I am dismayed when I look at the list of measures in our Registry. Unfortunately, the measures have a largely orthopedic and body part focus, which we know does not get at the crux of the older adult's function and mobility disability. I think the Academy should take the lead in establishing the recommended list of outcome measures for older adults, similar to what the Academy of Neurological Physical Therapy has done. So I'm going to start that endeavor with my list.

We need wholistic measures such as the Short Physical Performance Test19 that measures the multiple domains of walking speed, strength, through the 30-second sit-to-stand, and static balance, 3 domains that should be measured in every encounter across every setting.

The 6-minute walk test is a useful tool for most folks in most settings to evaluate abilities to negotiate community distances without undue effort. This is the test that gets at endurance. The test is limited by leg strength as well as breath control, both useful things to ascertain as limitations to community mobility. Some therapists like the 2-minute version as it takes less time, but 4 more minutes can tell me a lot more about how the person reacts to staying in motion for only 6 minutes. And remember, the person doesn't have to walk 6 minutes. The score is the score and will reflect the inability to walk 6 minutes. It is also useful as the minimum distance for ascertaining mobility disability is ¼ mile (1200 ft or 400 m).

And finally, a dynamic balance test is needed in the battery. I like the Four Square Step Test20 because of its simplicity. It quickly evaluates agility and balance reactions and perhaps a bit of cognitive ability.

These outcome measures have good metrics that can be used as outcome measures and predictive measures and can inform impairments. I believe this battery should be a standard of care for any older adult. The results of outcome measures can be empowering and informative, adding enormous value to patient encounters and to our outcomes.

In addition to standardizing history questions and outcome tools, screening for vulnerability through the conditions of arthritis, frailty, and diabetes will help manage these chronic conditions and may slow their progression, thus reducing their role in mobility disability or even excess disability. The evidence is very strong for the impact of exercise and other physical therapy strategies to help affect the symptoms of chronic diseases.21–23 In addition, identifying and intervening in the prestates of these conditions can provide additional value, especially in the outpatient setting, before actual diagnoses are made. For example, preclinical arthritis, where symptoms exist without imaging findings, is an ideal time to provide education and exercise instruction to reduce the risk of mobility disability.24 Since the 2 earliest indicators of prefrailty are weakness and reduced physical activity,25 this is the time for advocating for exercise/physical therapy. It is far more effective to begin an exercise program in the “prestages” than in full-blown disease or frailty. Screening for prediabetes is so easy, just by having patients take a very quick online risk tool that asks 10 questions. And finally, assessing prefalls vulnerability through fear of falling questions or questionnaire or dynamic balance tests will allow us to intervene early, before a disastrous fall results.

So what does a comprehensive and person-centered evaluation look like to an older adult consumer? It delves into the chief concern and what matters the most, but also comprehensively assesses risk for geriatric syndromes and preclinical disease states that may not be evident, and it uses user-friendly performance measures that have results that are made meaningful to the patient in the context of their aging trajectory. That is practicing at the top of our license.

My fourth exemplar is about interventions. Interventions must be informed by best practices and evidence, then implemented with appropriate challenge, relevance, and creativity to empower the patient and to achieve what matters the most to the patient.

Best practices and evidence-based interventions include exercise prescription, joint mobilizations, and evidence-based balance interventions such as facilitating reactive balance control. If everyone could master these, our profession will have come a long way in addressing much of the pain and mobility disability that plagues older adults.

What do I mean by appropriate challenge? We can do better in challenging our patients. While I believe the intensity issue has gotten a lot of traction in recent years, helped immensely by Geros' clever hash tags #Old is not Weak and #End 1 RM living, much remains to be done to get every therapist on board to deliver the appropriate intensity in innovative and creative ways. It was in 1993 that Maria Fiatarone first published a study demonstrating the powerful effects of high-intensity training on older folks with mobility disability in long-term care.26 With the preponderance of evidence about the effectiveness of high-intensity exercise, it shouldn't take another 30 years for every therapist to implement high-intensity exercise. We need to continue to publicize that every older adult can engage in functional strength training. It just takes a physical therapist that knows the evidence, has the desire to implement it in creative ways, and who has high enough expectations for the older adult.

High-interval training, shown to be highly successful and acceptable to older individuals with chronic obstructive pulmonary disease, heart failure, type 2 diabetes, and coronary artery disease, is a newer tool that may make the most effective dose feasible and attainable. Exercising to failure is the most effective way of gaining strength. The degree of intensity is most associated with improvement in physiological parameters such as cardiovascular fitness. It is fitness, not physical activity, per se, that is the strongest predictor of morbidity premature mortality and health care expenditures. Are we the kind of coach that elicits the kind of effort to achieve these outcomes?

Appropriate intensity also applies to balance. We can do better than ask our patients to stand in a static position and toss a balloon as a primary balance intervention. Patients stay engaged when they are challenged, even while admitting it is hard. One only has to observe the large smiles on the face of a patient that successfully completed a highly challenging task in which they had failed earlier. Claire McLean of Rouge Physical Therapy posts some amazingly creative videos on her Facebook site: https://www.facebook.com/rogueptwellness/

Reactive stepping is a powerful, evidence-based intervention that demonstrates rapid effects when implemented. But are we implementing this powerful tool? Or are we so concerned about keeping the patient safe through overguarding that they are never allowed to lose their balance, much less learn to recapture it? We can do better! The evidence is so clear about what it takes to improve balance that will reduce falls. The Australians have been particularly prolific on this subject. Appropriate dose (25 weeks minimum, 2-3 hours/week), minimize hand support, challenge the base of support appropriately,27 multicomponent/multitask,28 utilize high-intensity strengthening to improve core, and lower limb stability, etc.

And yet, when I review physical therapy records, the number 1 intervention for balance is tossing a balloon. Really? Where is the evidence, much less reasoning that tossing a balloon in a static position, no matter the nature of the surface improves balance that matters? We have a mandate that we must provide skilled care if we accept Medicare payment for our interventions. If our balance interventions are insufficiently challenging, it is doubtful we are providing skilled care. Yes, it requires our 100% undivided attention. Yes, there are risks involved. That is why it is called skilled care. We need to focus on dynamic movement that allows a person to lose their balance in a safe environment while they develop the skills to consistently and successfully recover their balance. We need to be experts at enhancing reactive balance control so the older person gains confidence that they can recover their balance when they lose it—and lose it they will if they are physically active. Are we so afraid of doing harm that we don't do any good?

Joint mobilization is our second most effective intervention for joint pain and stiffness that impacts functional mobility. It is particularly effective on stiff joints—the kind we find in older people.29 Many times, my students finally experience the movement that occurs in joint mobilizations when they apply them to older folks. And in my experience, it just takes a few sessions before improved range and decreased pain is experienced. It is one of my first “go-to interventions” for hip, back, and knee pain and most of the time it provides dramatic relief. I cannot urge you enough to use joint mobilizations of sufficient intensity early and regularly. If you don't feel comfortable with joint mobilizations, go take a course or 2. It's that important and that effective.

We also need to consider creativity and individuality. Therapists often get into a rut ... doing the same exercises for each patient, at each treatment. I used to ask my entry-level students in the first class of the therapeutic exercise course to write down the 5 most-frequently observed exercises used in physical therapy. These 5 are amazingly consistent across students, regardless of the settings they've observed. I've often said, when we are bored, you know the patient is. Christine Prevett of Geros (https://www.geroshealth.com/) suggests that we have a responsibility to design activities that patients want to do. I am intrigued with Parkour, an exercise method that enhances agility and coordination and can be adapted for older adults.30 There are so many different ways to build strength, power, and balance that no 2 treatment sessions should be alike. It's one of the reasons I love boot camp for my own workouts ... each day it's different.

So what do quality interventions look like to a consumer? They are interventions that are individualized, challenging, creative, and relieve pain and improve mobility in just a few sessions. They are interventions that could not be performed by anyone except a skilled physical therapist. And they are interventions the consumer knows made a difference. And when asked what the patient thought of their therapy, the response is “My therapist is hard” rather than “my therapist was nice.”

My fifth and final exemplar is to advocate for the role of physical therapy to promote intentional aging across the continuum of care.

However, we should only do this when we are sure the product we are advocating for, geriatric physical therapy, is consistent and effective. In other words, it is current, person-centered, with a standardized examination, and evidence-based interventions of the appropriate dose. With these practice elements in place, and I believe they are in many of your practices, geriatric physical therapists should be promoted as the musculoskeletal experts for older adults, being the first entry point into the health care system with direct access under Medicare. We should be providing annual visits, proclaim a positive message about physical activity, provide exercise classes, and model intentional aging in ourselves.

When my friends tell me they have a neck issue or a back issue or a knee issue and are going to see an orthopedist (“surgeon”), I wonder at why they aren't considering a nonsurgical alternative. They just don't think about physical therapy as the first line of defense, and yet that is where we are the most effective.

We need to do a better job about sharing the evidence of what works (exercise and manual therapy) and the questionable value of common procedures oriented toward the “fixing” approach such as imaging studies and certain surgical procedures. We need to shift the thinking from a “fixing” approach to a management approach where the patient is boss and person-centered care is central to the encounter. We need to counter the pharmaceutical ads with ads similar to the one run by the Centers for Disease Control and Prevention, Arthritis Foundation and NYS titled “Physical Activity. The Arthritis Pain Reliever.” And how many of you get really annoyed with the pharmaceutical commercials? Isn't it amazing the list of adverse side effects? Who on earth wants to take something that has that much risk?

Older adults have a preference for positive messages that are emotionally meaningful.31 We need to put more emphasis on what is helpful rather than what is medical. Wouldn't it be amazing if the Academy and APTA partnered in a public health campaign that said something like this ... Do you have hypertension and take medications that make you feel tired, light headed, or off-balance? Did you know there is a treatment that not only lowers your blood pressure, but has positive effects on your mood, cognition, joints, weight, heart function, and your energy? And it's free! Exercise is the gold standard to treat hypertension that allows you to control the dose and the method. You can walk by yourself, or take a class, at your convenience. What could be better than that? Exercise—consult with your physical therapist to find the best dose for you.

We need to embrace the opportunity to promote the value of physical therapy.

I believe physical therapists should be the first entry point for musculoskeletal and mobility issues. That means we need to be direct access providers under Medicare. Direct access is cost-effective and expedient. And it gets at promoting the physical therapist as a primary care provider allowing us to be drivers of wellness that builds capacity and prevents excess disability. Medical remedies will always have a place in a person's physical health, but physical therapy that supports the maintenance of health and well-being, and works with the person, rather than on them, are increasingly important in the future.32 I was sharing with a friend my belief that physical therapists should be the first line of action for any musculoskeletal concern, and she admitted to not knowing that physical therapists do not need a referral. But even knowing that, a student told me her CI's clinic refused to see anyone without a referral—instead of assisting the patient in getting a referral! What a lost opportunity, not just in patient relations, but in advocating for direct access physical therapy!

Older adults experience a lack of coordinated care, a stated frustration of many elders when surveyed about their needs. They want coordinated care and education about self-management. One mechanism is the provision of annual visits that will track their mobility and balance abilities from year to year—objectifying any decline and providing self-management education. In 2018, thanks to the advocacy of the Academy, the House of Delegates passed the policy recommending that all individuals visit a physical therapist annually. The APTA template is available for members on the APTA Web site. There are other short (eg, SAFE, Senior Fitness Test) and longer tools such as the AFIT. And it was recently demonstrated in an article in the Journal of Geriatric Physical Therapy that the majority of people who participated in screening using the AFIT would do so again, and just under half would pay for it.33 These are promising results for the value of the annual visit. And don't forget the geriatricians. They long to work with a physical therapist that shares their same values of management and promoting capacity throughout life. The book Elderhood by geriatric physician Louise Aronson,2 describes the joys and challenges of working with elders. Throughout the book she mentions the underappreciated value of physical therapists by medical specialists, other than geriatricians! I am also encouraged.....supervision that may limit us from practicing at the top of our license as compared with many state practice acts.

Another way we need to advocate for what we do and to promote intentional aging is to think in terms of a public health approach. Dustin Jones of Geros (https://www.geroshealth.com/) wrote to me that “If we only do things that we can get reimbursed for, we are tremendously limiting our impact on society.” One of the easiest and effective ways is advocating for and encouraging adherence of the 2018 Physical Activity Guidelines. We know that engaging in physical activity throughout the lifespan has many benefits. So there is no argument that regular physical activity and a minimum of 150 minutes per week of moderately-intense exercise that includes aerobic and strengthening is the best antidote for the disability associated with aging. Yet less than 20% of US older adults meet these physical activity guidelines, with 65% of older adults engaging in prolonged sitting behaviors.34 And inactivity is 30% higher in those with a chronic disease. I agree with Dustin Jones, who believes physical therapists must get out of our traditional health care silos and get into the community to help older folks build their capacity. He specifically talks about physical therapists becoming involved with the Senior Games, but his idea can be extended into any nontraditional environment such as providing exercise classes and fall prevention activities, which are bridges to nonskilled care. I am a particular advocate of the value of community-based exercise classes for those folks in the third age ... in their 50s to 80s. Exercise classes are a great way to offer something to your community, to make exercise accessible, and to provide older adults with a skilled instructor, which enhances their confidence. Exercise classes should be our pro bono community work. I have delivered exercise classes in a variety of settings for many years and it has taught me so much—-in addition to providing a valuable benefit to those who participate. I urge every one of you to commit to providing two 30-minute class sessions a week (that's only 1 hour/week)—it is such an easy way to promote intentional aging.

While we are delivering community exercise, we have the opportunity to reframe the physical activity message. The majority of folks know the benefits of physical activity, but don't do it. Refocusing our messaging to positive benefits and attributes of movement may help. This recent article titled “A life fulfilled: positively influencing physical activity in older adults–a systematic review and meta-ethnography”35 is a wonderful review of older people's perspective of the value of exercise. The authors posit that transition to older age can challenge people's sense of self and their role in life.35 Physical activity can help regain feelings of purpose, feeling needed in group activity, and creating habitual routine and structure to the day. In turn, participating in regular, structured physical activity builds self-esteem, which contributes to a fulfilling older age. Physical activity can provide a means by which older adults can gain some control over their aging process, turning the negative decline and decay paradigm into a purposeful, socially connected, and usefully engaged life, despite the many transition events that come with aging.35

And lest you think that I'm leaving out frail folks who are beyond community exercise classes, a neat little strategy for those who have serious barriers to physical activity, suggested by the WHO, is to engage folks in 10-minute exercise “snacks.” Even 20-second intervals every 1 to 4 hours has a positive effect and may be especially good for those who don't want to do anything. We can do better.

Finally, I believe we have an obligation to model intentional aging by practicing healthy behaviors, especially exercise. Through our own fitness, we can show that aging is not decline and decay, no matter what chronic disease you might have. And lifelong engagement in exercise has important implications for the likelihood of being physically active later in life. The earlier you start, the more likely you will still value exercise in your older years.

Dustin Jones has a different take on why therapists should to be fit. He shares in a podcast that before he got serious about his own strengthening, his patient interventions included a lot of supine exercises by the end of day, just because he was fatigued! He cites several reasons why we should be physically strong:

  • To handle the physicality of our jobs—especially as we get older
  • To gain perspective on movement and how to facilitate better movement in our patients
  • To demonstrate good exercise technique and form
  • To be more likely to challenge our patients—are we holding them back because we can't easily do what they need to do?
  • To have a greater variety of exercises
  • To develop quickness in our reactions so that we can safely engage our patients in reactive balance strategies
  • To be an inspiration and model of intentional aging

Every one of us needs to be engaging in 150 minutes per week of moderate-intense exercise that includes strengthening. I promise you that it will make you a better therapist and will help you be the kind of older person you intend. That's intentional aging! And that's my challenge to you!

CLOSING

In closing, I've put forth many ways we demonstrate value to society and our consumers, aging folks, through physical therapy. I have also suggested 5 exemplars/standards that demonstrate our value and help the consumer and referral sources know what to expect from physical therapists working with aging folks. I think a focused public health message about the specific value of physical therapy for older adults is overdue and timely. We need to be passionate about promoting the magic pill of exercise of which we are the experts. Exercise is too important to keep quiet and our role is too critical not to be proclaiming it any chance we can.

We can do better in building more consistency into our professional practice, to hold each other accountable, so as to not risk that one bad encounter that taints a physician's or patient's view of what it means to “get physical therapy.” Our value is too great to risk some bad apples causing older folks to dismiss physical therapy or worse, for older folks to not see any benefit. Stop solely focusing on selling your value to your third party payers & referral sources. Those are obviously important, but if we are to change our public perception—we need to change how our end user perceives our value. Demonstrating our value is going to come from practicing at the top of our license, not doing the minimum. And we need to use our earned credentials, including that of Doctor. Our patients deserve to know our knowledge base is broad and deep and that we have earned specific credentials such as a doctorate in physical therapy. My patients appreciate knowing I'm a Doctor of Physical Therapy. I give them permission to call me Dale in my introduction, but I share my earned credential. Using our earned credentials is part of our self-advocacy for ourselves as physical therapist professionals and for the value of what we provide. There are no reasons not to use our earned credentials and we must change the culture that discourages the use of this.

David A. Nicholls, a physiotherapist in New Zealand, states in his article titled “Aged care as a bellweather of future physiotherapy,”32 that person-centered care, grounded in science with a humanistic approach, emphasizing the management of chronic conditions and the capacity of an older person, may be the paradigm for how physical therapy might respond to the changing political and social economy of health care. I couldn't agree more. The challenge is ours. We can do better.

Thank you.

—Dale Avers, PT, DPT, PhD, FAPTA

REFERENCES

1. Centers for Medicare & Medicaid Services. CMS Value Based Care. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/meetings/2018/nacnep-sept2018-CMS-Value-Based-Care.pdf. Accessed May 4, 2020.
2. Aronson L. Elderhood. New York, NY: Bloomsbury Publishing; 2019.
3. Warmoth K, Lang IA, Phoenix C, et al. “Thinking you're old and frail”: a qualitative study of frailty in older adults. Ageing Soc. 2016;36(7):1483–1500.
4. Jenkins JA. Disrupt Aging: Reinventing What It Means to Age. New York, New York: Hachette Book Group; 2016.
5. National Prevention Council. Healthy Aging in Action. Washington DC: US Department of Health and Human Services; 2016. https://www.cdc.gov/aging/pdf/healthy-aging-in-action508.pdf. Accessed September 1, 2019.
6. World Health Organization. Active Ageing: A Policy Framework Active Ageing. Geneva, Switzerland: World Health Organization; 2002. http://www.who.int/hpr/. Accessed May 4, 2020.
7. American College of Surgeons. Optimal Resources for Geriatric Surgery: 2019 Standards. https://www.facs.org/-/media/files/quality-programs/geriatric/geriatricsv_standards.ashx. Published 2019. Accessed May 4, 2020.
8. Wong RA, Barr J, Avers D, Ciolek C, Klima D, Thompson M. Essential competencies in the care of older adults at the completion of the physical therapist professional program of study. J Phys Ther Educ. 2014;28(2):91–93.
9. Bures F. On the Body as Machine. UNDARK Truth, Beauty, Science. https://undark.org/article/mind-machine-medicine-militaristic-healthcare/. Published July 2016. Accessed August 12, 2019.
10. Chonody JM. Addressing ageism in students: a systematic review of the pedagogical intervention literature. Educ Gerontol. 2015;41(12):859–887.
11. Chen H, Smith SS. Item distribution in the berg balance scale. J Geriatr Phys Ther. 2019;42(4):275–280. http://insights.ovid.com/crossref?an=00139143-900000000-99698. Accessed March 22, 2019.
12. Lusardi MM, Fritz S, Middleton A, et al. Determining risk of falls in community dwelling older adults: a systematic review and meta-analysis using posttest probability. J Geriatr Phys Ther. 2017;40(1):1–36.
13. Allison L. Editor's message: reading, writing, rigor, and relevance. J Geriatr Phys Ther. 2019;42(4):207–208.
14. The American Geriatrics Society Expert Panel on Person-Centered Care. Person-centered care: a definition and essential elements. J Geriatr Soc. 2016;64(1):15–18.
15. Tripicchio B, Bykerk K, Wegner C, Wegner J. Increasing patient participation: the effects of training physical and occupational therapists to involve geriatric patients in the concerns-clarification and goal-setting processes. J Phys Ther Educ. 2009;23(1):55–63. http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010324894&site=ehost-live.
16. Bland MD, Birkenmeier RL, Barco P, Lenard E, Lang CE, Lenze EJ. Enhanced medical rehabilitation: effectiveness of a clinical training model. NeuroRehabilitation. 2016;39(4):481–498.
17. Lentz E. EMR Therapist Guide. https://wustl.app.box.com/v/EMRTools/file/67391898765. Published 2016. Accessed May 12, 2020.
18. Jette AM. Moving from volume-based to value-based rehabilitation care. Phys Ther. 2018;98(1):1–2.
19. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49(2):M85–M94. http://www.ncbi.nlm.nih.gov/pubmed/8126356.
20. Moore M, Barker K. The validity and reliability of the four square step test in different adult populations: a systematic review. Syst Rev. 2017;6(1):187.
21. Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2012;2(2):1143–1211.
22. Desveaux L, Beauchamp M, Goldstein R, Brooks D. Community-based exercise programs as a strategy to optimize function in chronic disease: a systematic review. Med Care. 2014;52(3):216–226.
23. Mitchell T, Barlow CE. Review of the role of exercise in improving quality of life in healthy individuals and in those with chronic diseases. Curr Sports Med Rep. 2011;10(4):211–216. http://journals.lww.com/acsm-csmr/Fulltext/2011/07000/Review_of_the_Role_of_Exercise_in_Improving.11.aspx.
24. Mahmoudian A, Van Assche D, Herzog W, Luyten FP. Towards secondary prevention of early knee osteoarthritis. RMD Open. 2018;4(2):e000468.
25. Xue QL. The frailty syndrome: definition and natural history. Clin Geriatr Med. 2011;27(1):1–15.
26. Fiatarone MA, O'Neill EF, Doyle N, et al. The Boston FICSIT study: the effects of resistance training and nutritional supplementation on physical frailty in the oldest old. J Am Geriatr Soc. 1993;41(3):333–337. http://www.ncbi.nlm.nih.gov/pubmed/8440860. Accessed February 9, 2019.
27. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019;1:CD012424.
28. Dipietro L, Campbell WW, Buchner DM, et al. Physical activity, injurious falls, and physical function in aging: an umbrella review. Med Sci Sports Exerc. 2019;51(6):1303–1313.
29. Alkhawajah HA, Alshami AM. The effect of mobilization with movement on pain and function in patients with knee osteoarthritis: a randomized double-blind controlled trial. BMC Musculoskelet Disord. 2019;20(1):452.
30. Musholt B. 5 Parkour Concepts for Healthy Aging—Ben Musholt. https://www.benmusholt.com/parkour/parkour-and-healthy-aging/. Published 2017. Accessed May 4, 2020.
31. Strough J, de Bruin WB, Peters E. New perspectives for motivating better decisions in older adults. Front Psychol. 2015;6:783.
32. Nicholls DA. Aged care as a bellwether of future physiotherapy [published online ahead of print August 14, 2018]. Physiother Theory Pract. doi:10.1080/09593985.2018.1513105.
33. Puthoff M. Participants perceptions and the implementation of a physical fitness screen for aging adults [published online ahead of print July 31, 2019]. J Geriatr Phys Ther. doi:10.1519/JPT.0000000000000241.
34. Singh R, Pattisapu A, Emery MS. US Physical Activity Guidelines: current state, impact and future directions [October 17, 2019]. Trends Cardiovasc Med. doi:10.1016/j.tcm.2019.10.002.
35. Morgan GS, Willmott M, Ben-Shlomo Y, Haase AM, Campbell RM. A life fulfilled: positively influencing physical activity in older adults—a systematic review and meta-ethnography. BMC Public Health. 2019;19(1):362.
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