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APTA Michigan Lines is a blog to promote collaboration between professionals and students of the physical therapy profession in Michigan.

The goal is to create a space where individuals from many backgrounds can share knowledge and experiences with each other and the community.

We would love to hear from you about a topic you are passionate about. Posts are submitted by individuals and reviewed for posting. You can submit yours by emailing new blog items to contact@aptami.org


 

Could you recognize the signs and symptoms of delirium, as opposed to depression and dementia in your elderly patient? While all three can coexist simultaneously, the ability to differentiate can be difficult and is of great importance when working with older adults. Delirium in older adults is commonly undiagnosed, misunderstood, and responsible for unnecessary hospitalizations. It is estimated that delirium affects 14% to 56% of all hospitalized elderly patients. Each year in the US, at least 20% of the 12.5 million patients over the age of 65 experience some form of complication due to delirium.1

Delirium can be defined as a transient mental disorder causing a sudden and rapid change in cognition, lasting from a few hours or up to a few months. Clinical features of delirium include a reduced ability to focus on an external stimulus, inability to shift attention to a new external stimulus, and disorganized thinking which is manifested by rambling or incoherent speech.2 Symptoms of delirium can be classified as hyperactive, hypoactive, or a mixed combination of both. Common symptoms can include: a reduced awareness of their environment, decreased activity level, poor short-term memory, disorientation, difficulty speaking or understanding speech, anxiety, apathy, fear, aggression or anger, restlessness, sleep disturbance, and lethargy. While these symptoms can fluctuate, they are often absent during the day, but worsen in the evening.3

Dementia is a neurocognitive disorder characterized by a slow gradual onset of reduced ability to reason and make sound judgments, loss of social skills, and development of regressed or antisocial behaviors.2 Common forms of dementia include Alzheimer’s disease, frontotemporal lobe or Pick’s disease, Lewy body dementia, vascular dementia, Parkinson disease, Creutzfeldt-Jakob disease, and Wernicke-Korsakoff syndrome. Signs and symptoms of dementia include memory loss, executive dysfunction, wandering, abnormal gait, falls, impaired visual spatial ability, apraxia, agnosia, and depression.3,4

Depression is a mood disorder characterized by a slow gradual onset that can cause cognitive issues and affects the way an individual feels and behaves.3 Depression can be classified as clinical depression or depressed mood depending on the presentation and duration of symptoms. Common signs and symptoms of depression include persistent feelings of sadness, withdrawal, unexplained weight loss or gain, sleep disturbance, anxiety, fatigue, trouble concentrating, and thoughts of death or suicide.3,5 Psychiatrist Dr. Bonnie Wiese states, “older persons may demonstrate apathy, fatigue, somatic complaints, sleep disturbances, anger out of proportion to incident, and other atypical presentations rather than tearfulness or sadness.”5 These atypical presentations should be considered when working with the older adult population.

As clinical professionals, it is our duty to identify these signs and symptoms as early as possible. Recognizing the onset, duration, and course of these symptoms will help in determining if they are caused by delirium, dementia, or depression. If symptoms fall outside of your professional scope of practice, a referral should be made to the patient’s primary care physician, neurologist, or neuropsychologist.

References

  1. US Department of Health and Human Services. CMS statistics. Washington, DC: Centers for Medicare and Medicaid Services; 2004. (publication no. 03445)
  2. Staples W, Heitzman J, Kegelmeyer D. Geriatric Physical Therapy. New York: McGraw-Hill; 2016.
  3. Marshall, Katherine DNP, NP, PMHCNS-BC, CNE; Hale, Deborah MSN, RN, ACNS-BC Delirium, Dementia, and Depression, Home Healthcare Now: October 2017 - Volume 35 - Issue 9 - p 515-516
  4. Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5(4):210-220. doi:10.1038/nrneurol.2009.24
  5. Harris M. Cognitive Issues: Decline, Delirium, Depression, Dementia. Nurs Clin North Am. 2017;52(3):363-374.

 


It’s important as health care professionals and physical therapists that we do our best to ensure the general health and well being of our patients. As physical therapists we are specifically focused on encouraging our patients to stay active, no matter what age, in order to ensure our patients have a better quality of life. Aging is a normal part of life, however, our bodies sometimes need a little extra help to continue to stay healthy. That’s where dietary supplements like vitamins and minerals come in. As our bodies age we have different needs, so certain nutrients become more important than they were when we were younger. It’s important to talk about these with your patient, if it will help with their prognosis and healing.1 These supplements can be added to your diet to help your bones, muscles, nerves and cells stay healthy, as well as lower your risk of health problems like arthritis and osteoporosis.2 Supplements come in many forms such as pills, powders, capsules, gel capsules, extracts, tablets or liquids; these can be added to any foods or drinks.2 The patient's diet can be changed so they are getting a variety of healthy foods to help their body get the vitamins or minerals that it needs.

Vitamin D is important for older adults because it works with calcium to help maintain bone health.1 Good sources of vitamin D include fatty fish such as salmon, milk products and eggs.3 Vitamin B6 helps the body use and store energy from protein and carbohydrates and form red blood cells.2 Vitamin B6 can be found in potatoes, fish, and bananas.3 Vitamin B12 is especially important for older adults because it helps keep your red blood cells and nerves healthy. Older adults tend to have trouble absorbing this vitamin through food, so many times, doctors may recommend taking a B12 supplement.2 Those most likely to develop a vitamin B12 deficiency are strict vegetarians or vegans because B12 is mostly found in animal foods such as meat, fish and milk.3

           As mentioned, calcium and vitamin D work together to create and maintain strong bones and teeth. Older adults, especially older women, are most at risk for bone loss and osteoporosis.3 Calcium can be found in dairy products, dark green leafy vegetables and canned fish. Potassium is an electrolyte that works to help your nerves function and contract your muscles.1 Potassium has also been found to lower your risk for high blood pressure and it can be found in many fruits, vegetable products, beans and coffee.3 Lastly, magnesium is a mineral that helps with function of the nerves, muscles and immune system. Magnesium is often found in foods containing dietary fiber, which is important for maintaining regular bowel movements. Green leafy vegetables, whole grains and cereals contain a lot of magnesium and fiber.1

As physical therapists, we are not allowed to prescribe supplements or medications so it’s important to let your patient know this if they come to you with questions. However, dietary supplements are a good subject for you to be educated on as a healthcare professional and can be a good subject to talk about with your patients, if you think they could help benefit them. Your patients may also come to you with questions on supplements they think they want to take or are taking and it’s important you have the information to help educate them on pros, cons, and safety concerns. One question your patient might have is, are dietary supplements like vitamins and minerals safe? The U.S Food and Drug Administration (FDA) is not required to look into the safety of vitamins and minerals before they are sold, so it is important to do research before you purchase them.2 However, if the FDA hears concerns about a specific supplement, they can issue warnings about the product and can take supplements that appear to be unsafe off of the market.2 The Federal Trade Commision also investigates reports of ads that might misinterpret what dietary supplements do.2 Even though the FDA does not have the authority to directly monitor supplements, they are still able to investigate reports and remove bad ones from the market. There are also a few private groups such as U.S Pharmacopeia and NSF International that have their own “seal of approval” for supplements. This seal of approval indicates that they are following good manufacturing procedures, contain what is listed on the label, and do not contain harmful levels of ingredients that do not belong there.2 So if your patients are concerned about the safety of dietary supplements, recommend that they do their research ahead of time and find a brand with the “seal of approval” from these private groups to ensure these supplements have been investigated.2 Lastly, it’s always important to end your conversation with your patient by letting them know that before they start taking any type of dietary supplement that they need to consult with their doctor first.

References:

  1. Klemm, RDN, CD, LDN S. Special Nutrient Needs of Older Adults. EatRight. https://www.eatright.org/health/wellness/healthy-aging/special-nutrient-needs-of-older-adults. Published May 21, 2020. Accessed May 17, 2021.
  2. Dietary Supplements for Older Adults. National Institute on Aging. https://www.nia.nih.gov/health/dietary-supplements-older-adults. Published April 23, 2021. Accessed May 17, 2021.
  3. Vitamins and Minerals for Older Adults. National Institute on Aging. https://www.nia.nih.gov/health/vitamins-and-minerals-older-adults. Accessed May 17, 2021.

 


 

 

Image from Functional Training for Older Clients. By Zac Martin, https://www.theptdc.com/functional-training-older-clients.

In the physical therapy field, we’re no strangers to the benefits of regular physical activity and exercise to improve health outcomes, increase functional capacity, and create an overall better quality of life. This holds true for the older adult population, a growing demographic as we see Baby Boomers entering this next phase of life. Older adults represent a rapidly growing demographic of the population. The 2019 census indicated more than 54 million U.S. residents compared to 40.3 million reported in the 2010 census1. Participation in regular physical activity and exercise is proven to have substantial health benefits, delay physiological dysfunction associated with aging, and help prevent chronic disease2. Yet research suggests that only 22% of adults over the age of 65 years old meet the appropriate physical activity recommendations³. Furthermore, despite the known benefits of exercise, many clinicians remain hesitant to prescribe exercise to an older population4. This piece outlines the appropriate exercise parameters for this population, as well as how we can implement these recommendations to our patients in this demographic.

 

BENEFITS OF EXERCISE

Healthy aging and maintenance of functional capacity require consistent physical activity with prescription of higher intensity, longer duration and greater frequency being particularly beneficial for older adults. Some short-term benefits of exercise include reducing blood pressure and risk of anxiety, depression and sleep disturbances. In the long-term exercise promotes brain, heart and bone health while reducing risk of cancer, obesity and falls⁵. Physical activity is associated with greater executive function, memory and processing speed as well as lower risk of dementia and other cognitive impairments. It also reduces the risk of multiple types of cancers including bladder, breast, gastrointestinal and lung, and regular exercise improves quality of life with lower mortality risk in cancer survivors. Risk of cardiovascular disease and stroke are reduced by following the aerobic activity guidelines mentioned below. Multimodal physical activity leads to a reduction in risk of falls, and resistance training via the lifting recommendations mentioned below can slow the loss of bone density associated with aging making fractures less likely if an older person is to have a fall or experience other impact. Overall risk of mortality is lower in physically active individuals; arguably more importantly, improvements in physical function and injury reduction are observed when meeting the recommended aerobic, and muscle strengthening exercise recommendations⁶.

CARDIO

Cardiovascular exercise has been shown to have multiple beneficial effects in the senior population. Some of those effects include a reduced maximal heart rate in response to exercise, increased cardiac output due to increased stroke volume, and improved peak VO2 levels due to increased perfusion and arterial compliance. All of these beneficial effects lead to improved cardiovascular performance despite physiological aging⁷. The American College of Sports Medicine’s exercise guidelines for seniors recommends 30-60 minutes of moderate intensity physical activity per day for a total of 150-300 minutes per week. Moderate physical activity indicates approximately 40-60% of an individual’s heart rate reserve, or approximately 5-6/10 of perceived physical exertion. This can be performed in shorter bouts of 10 minutes at a time. Alternatively, at least 20-30 minutes of more vigorous activity may be performed each day for a total of 75-100 minutes/week at 60-90% of HRR. This may also consist of an equivalent combination of moderate to vigorous activity¹.

This may be performed in a variety of ways, and to see the most success, should pertain to the individual’s interests. For example, walking, biking, and aquatic exercises offer great opportunities to meet these guidelines and yield cardiovascular benefits without imposing excessive orthopedic stress.

TO LIFT OR NOT TO LIFT?

While cardiovascular fitness is crucial, resistance training should not be overlooked and can counteract physiological changes related to aging, including help preserve muscle mass, strength, and bone density. Resistance training can also increase mobility, function and independence, which is extremely important to our older individuals. Increased strength and mobility will also help prevent falls which in turn can prevent serious medical complications such as fractures and increase quality of life⁸. Resistance training is beneficial for psychological wellbeing and can be tailored to the patient's skill level, meaning that each and every older adult is able to perform resistance training in some capacity and will likely benefit from it. The ACSM recommends older adults who have previously been sedentary begin at 50% of a 1 rep max and gradually increase load overtime¹. This can be applied to a variety of resistance training exercises, including squats, deadlifts, overhead presses, and other movements specific that promote functional independence.

 

WHAT CAN WE DO?

As physical therapists and physical therapy students, we have a role in effectively prescribing safe levels of exercise to enhance quality of life and promote optimal health amongst all populations. The ACSM outlines useful criteria and parameters of rexercise. Prior to beginning a new exercise regimen, we play a crucial role in screening for risk factors. This includes taking patient vitals regularly, implementing an orthopedic screen, movement assessment, and monitoring use of medication.

 

Furthermore, providing patient education on both the importance and benefits of regular exercise should be provided in order to help promote adherence and address potential barriers. We may also encourage and provide resources for group exercise classes, which may provide increased social support and encouragement to support long term success.

 

REFERENCES:

 

  1. United States Census Bureau. Stats for Stories: National Senior Citizens Day: August

21, 2020. https://www.census.gov/newsroom/stories/senior-citizens-day.html. Accessed June 1, 2021.

  1. American College of Sports Medicine. Chodzko-Zajko WJ, Proctor DN et al. American

College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009 Jul;41(7):1510–30.

  1. Zaleski AL, Taylor BA, Panza GA, et al. Coming of Age: Considerations in the

Prescription of Exercise for Older Adults. Methodist Debakey Cardiovasc J. 2016;12(2):98-104. doi:10.14797/mdcj-12-2-98.

  1. Barnes PM, Schoenborn CA. Trends in adults receiving a recommendation for

exercise or other physical activity from a physician or other health professional. NCHS Data Brief. 2012;(86):1–8.

  1. Centers for Disease Control and Prevention (CDC). Benefits of Physical Activity

https://www.cdc.gov/physicalactivity/basics/pa-health/index.htm. Page last reviewed April 5, 2021. Accessed June 1, 2021.

  1. U.S. Department of Health and Human Services. (2018). Physical Activity Guidelines

for Americans, 2nd edition. Retrieved from https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf

  1. Vigorito C, Giallauria F. Effects of exercise on cardiovascular performance in the

elderly. Front Physiol. 2014;5:51

  1. Fragala MS, Cadore EL, Dorgo S, et al. Resistance training for older adults: position

statement from the national strength and conditioning association. J Strength Cond Res. 2019;33(8):2019-2052.

 


Importance of physical activity for the geriatric population

According to the CDC, 54 million adults are over the age of 65 and that number is expected to increase to 71 million by 2030. Among the aging population comes a multitude of medical conditions and comorbidities that lead to disability and thus decreased function and independence. Physical activity is the common deterrent to combat the consequences of not only disease but a sedentary lifestyle that puts many older adults at risk for falls and increasing mortality.1 The challenge is encouraging older adults to participate in exercise and maintain an active lifestyle. A common barrier to exercise regardless of age is lack of time to engage in physical activity.2 Therefore, the ultimate goal as physical therapists and other healthcare and exercise providers is to determine the most effective, safe, and meaningful experience to benefit our geriatrics patients.

What is HIIT?

High Intensity Interval Training (HIIT) is a low volume exercise program characterized by vigorous intervals of physical activity at 80-95% of an individuals’ HRmax, interspersed by either passive or active recovery periods at low to moderate intensity. Completely customizable by activity, intensity, duration, and pattern of recovery, HIIT is a favorable choice when it comes to a low volume workout that yields effective results in physiological adaptations in skeletal muscle and cardiorespiratory performance similar and often superior to “matched-work” endurance exercise.3

Benefits of HIIT in Geriatric Population

Improvements in body composition (BMI and fat mass), cardiovascular health (resting HR and BP)4, and aerobic capacity (VO2max)5 are among the many health benefits seen as a result of implementing HIIT in the geriatric population. Participation in at least an 8-week HIIT program at 2x/week may demonstrate a sustained beneficial effect in maintaining a reduction in fat mass and functional performance (6-minute walk test and chair stand test) up to 4-weeks of detraining more so than exercising at moderate intensity, either interval or continuous.4 Additionally, HIIT does not tend to lead to compensations in daily physical activity and total energy expenditure levels in older adults, meaning that exercising at vigorous intensities is not likely to negatively affect the ability to perform activities of daily living and decrease energy levels related to cost of living.5 Interestingly, HIIT did not hinder nor seem to increase risk of falls in older adults exercising at higher intensities.6 A supervised HIIT program in the geriatric population has been shown to be feasible, safe, and demonstrate high adherence.6

How can I implement HIIT for my geriatrics patients?

Meaningfulness matters when designing any exercise program for patients of any age. The Generation 100 Study conducted a long term analysis of exercise patterns in older adults (age: 70-77) following either a moderate or high intensity exercise regimen for one year.7 For the geriatric population, exercising 2-3 times per week at high intensities is most common and seemingly most effective, according to both controlled and uncontrolled research.4-7 A common and easily feasible mode of exercise is walking, but cycling is also a popular choice when aiming to reach higher intensities. Exercise setting can be either indoors or outdoors depending on the preference of the patient, but most subjects partaking in HIIT preferred to exercise in a gym according to the Generation 100 Study.7 Other common choices of exercise utilized in HIIT were swimming and jogging. Even though women more so than men were more likely to participate in exercise with partners or friends, encouraging the geriatric patient to participate in group exercise is still important for positive social health.7

 

Example of HIIT for the Geriatric Patient

70 year old patient enjoys talking walks in the park

  1. Determine HRmax: (208 - .7 x age) = 159bpm
  2. Determine intensity 80 - 95% HRmax: 127 - 151bpm
  3. Mode of Exercise: Walking outside
  4. Frequency: 2x/week
  5. Duration: 4 bouts of 4 - minutes of high intensity walking (HR between 127-159 bpm) with 4-minute recovery periods, either passive resting or active recovery (i.e. slower walking pace at less than 65%HRmax); Total Time 32minutes
  6. Don’t forget warm up and cool down (10-minutes)

 

References
 

  1. Cdc.gov. 2021. Promoting Health for Older Adults | CDC. [online] Available at: <https://www.cdc.gov/chronicdisease/resources/publications/factsheets/promoting-health-for-older-adults.htm> [Accessed 1 June 2021].
  2. Centers for Disease Control and Prevention. 2021. Overcoming Barriers to Physical Activity. [online] Available at: <https://www.cdc.gov/physicalactivity/basics/adding-pa/barriers.html> [Accessed 1 June 2021].
  3. Gibala MJ, Little JP, MacDonald MJ, Hawley JA. Physiological adaptations to low‐volume, high‐intensity interval training in health and disease. The Journal of physiology. 2012;590:1077-1084.
  4. Coswig VS, Barbalho M, Raiol R, Del Vecchio FB, Ramirez-Campillo R, Gentil P. Effects of high vs moderate-intensity intermittent training on functionality, resting heart rate and blood pressure of elderly women. Journal of translational medicine. 2020;18:88-88.
  5. Bruseghini P, Tam E, Calabria E, Milanese C, Capelli C, Galvani C. High Intensity Interval Training Does Not Have Compensatory Effects on Physical Activity Levels in Older Adults. Int J Environ Res Public Health. 2020;17(3):1083. Published 2020 Feb 8. doi:10.3390/ijerph17031083
  6. Pires Peixoto R, Trombert V, Poncet A, et al. Feasibility and safety of high-intensity interval training for the rehabilitation of geriatric inpatients (HIITERGY) a pilot randomized study. BMC geriatrics. 2020;20:197-197.
  7. Reitlo LS, Sandbakk SB, Viken H, et al. Exercise patterns in older adults instructed to follow moderate- or high-intensity exercise protocol - the generation 100 study. BMC geriatrics. 2018;18:208-208.

 


Is getting your geriatric patients to participate in treatment sessions becoming a bit of a stretch? Do you feel like you are bending over backwards trying to come up with new programs for your geriatric patients? Yoga may be the solution to your problems since it has many physical and mental benefits for the geriatric population.

    As your patients age, it is important to incorporate a variety of activities into their everyday routine to ensure overall health and fitness. Yoga is a great way to meet this recommendation because it provides a variety of benefits across many domains of physical fitness. Yoga is well-known for its intricate poses that promote flexibility and balance. These poses can be modified to the geriatric patients level of fitness and progress as the person improves. The poses often require single leg stance or positioning one’s center of mass outside of their base of support. Maintaining these poses for an extended amount of time works to challenge the patient’s vestibular system to improve the strength of stabilizing muscles. Gait improvements have also been seen in the geriatric population as a result of participating in a regular yoga program. Yoga helps to increase lower extremity strength, such as hip extension, which allows for longer stride length. Additionally, yoga works to target core muscles for better abdominal activation, decreasing anterior pelvic tilt during ambulation, static sitting, and standing. This can help to reduce low back pain, which is a common complaint in this population. A lesser-known benefit of yoga is that it helps to strengthen bones as well. This is a great benefit for geriatric patients who are at high risk of osteoporosis and fractures. The combination of improved balance, strength, and mobility helps to prevent falls in the aging adult. Falls are one of the leading causes of injury in the geriatric population and often result in further complications. By preventing falls, yoga helps to give geriatric patients the physical ability and confidence to continue to live an active lifestyle.

Geriatric patients with comorbidities are at increased risk for depression and other mental health related conditions. These conditions in the geriatric population can go undiagnosed by healthcare providers and be assumed to be a part of normal aging, even though it’s not. Since yoga is considered a mind-body physical activity, it can help to address some of these mental health factors that may be present in the geriatric population along with the physical benefits previously mentioned. For these patients meditation via yoga can help to improve perceived mental health along with reducing the overall risk of depression. This makes yoga a valuable form of treatment to be utilized in the geriatric population since it can help prevent and treat mental disease.

Yoga can be a great adjunct to your geriatric patients’ plan of care, but before you commit to making your patients full-on Yogis, some factors need to be considered. Just like with other specialties of physical therapy, yoga may be best instructed by a physical therapist who has taken continuing education courses on it’s practice and execution in a clinical setting. Additionally, some patients may feel uncomfortable performing certain positions and transitions because they are fearful of falling. Addressing these concerns with your patients beforehand and offering modifications and extra assistance can ensure their safety while maximizing the benefits of yoga. Yoga should not be used in place of activities like gait and task specific training, as it may not be as effective in improving mobility or upper extremity function, but it can be a great way to add variety and fun to your treatment sessions.

Overall, yoga can promote the physical and mental health and wellbeing of geriatric patients in physical therapy. This helps to encourage the overall health promotion and safety of your geriatric patients. If yoga is implemented there are many different frequencies and durations that can be utilized. However, to maximize the effects of yoga, sessions should occur two times per week for at least 30-90 minutes at a moderate intensity. Although yoga can be perceived as a younger generation activity, don’t be afraid to include these techniques into your geriatric population's plan of care. Namaste.

 

References

  • Balk J, Bernardo LM. Using Yoga to Promote Bone Health and Reduce Fracture Risk in the Geriatric Population. Topics in Geriatric Rehabilitation. 2011;27(2):116-123. doi:10.1097/tgr.0b013e31821bff95.
  • Sivaramakrishnan D, Fitzsimons C, Kelly P, et al. The effects of yoga compared to active and inactive controls on physical function and health related quality of life in older adults- systematic review and meta-analysis of randomised controlled trials. Int J Behav Nutr Phys Act. 2019;16(1):33. Published 2019 Apr 5. doi:10.1186/s12966-019-0789-2
  • DiBenedetto M, Innes KE, Taylor AG, et al. Effect of a gentle Iyengar yoga program on gait in the elderly: an exploratory study. Arch Phys Med Rehabil. 2005;86(9):1830-1837. doi:10.1016/j.apmr.2005.03.01
  • Bankar MA, Chaudhari SK, Chaudhari KD. Impact of long term Yoga practice on sleep quality and quality of life in the elderly. J Ayurveda Integr Med. 2013;4(1):28-32. doi:10.4103/0975-9476.109548 - sleep article
  • Tulloch A, Bombell H, Dean C, Tiedemann A. Yoga-based exercise improves health-related quality of life and mental well-being in older people: a systematic review of randomised controlled trials. Age Ageing. 2018;47(4):537-544. doi:10.1093/ageing/afy044

 

 


Cardio drumming has existed for centuries among cultures in Africa, known as djembe drumming, as a cultural tradition performed during rituals and celebrations.1 Over the years, it has gained popularity for its emotional and physical benefits. It has transitioned from being a ritualistic activity to a modern way to get active. Cardio drumming combines the use of an exercise ball, a platform to hold it, and drumsticks to create a unique workout. Cardio drumming classes are popping up more and more each year. Among the new found popularity, a cardio drumming company called POUND was founded in 2011.2 POUND offers an aerobic component alongside strength training and conditioning, but also offers yoga and pilates-inspired movements.2 The social aspect and inclusivity of cardio drumming programs can benefit geriatric patients by encouraging movement throughout the week. Although there are variations of this activity that exist worldwide, the goal is to provide an alternative option for working out that keeps individuals motivated while benefiting both physically and emotionally.

There are many health benefits when it comes to exercise, especially in the geriatric population. As people become older it sometimes can be more difficult to engage in vigorous exercise. Common complications of aging include increased risk of obesity, osteoarthritis, neck and back pain, diabetes, and dementia.3 Finding fun alternative ways to exercise is important in the geriatric population to stay mobile, improve cardiovascular health, and prolong independence. Additionally, physical activity can decrease the chances of bone and muscle breakdown thus leading to a healthier, longer life. POUND uses specific songs to get an optimal fat burn within the 2-4 minutes song.2 Drumming distracts your brain from the high intensity work you are receiving, by having you focus on rhythm and volume (pound website). Taking a POUND class can improve timing, rhythm, coordination, agility, and endurance.2 These classes are designed for all age groups, and are geriatric friendly as they can be modified to the individual’s abilities. Weighted drumsticks are available for all levels of progression, and participants are able to select a pace that best suits them.2

In addition to physical health, drumming has been shown to improve mental health and cognition. Cardio drumming can reduce depression and anxiety, as well as improve social resilience.4 Older adults with dementia had improvements in cognition, upper extremity ROM and body composition when engaging in cardio drumming programs.5 Music incorporated into physical activity, much like how POUND is structured, can provide an even greater benefit to older adults with dementia. Exposing older adults to music during exercise has been suggested to improve visuospatial processing, and reduce grey and white matter loss in the frontal cortex, leading to a potential delay in cognitive decline.6

Cardio drumming continues to grow and provides a unique option for meeting daily physical activity requirements. Participating offers social, physical, and emotional benefits, and for the geriatric population, they have the added gain of improving effects associated with dementia. By implementing cardio drumming classes into more gyms, nursing homes, and senior centers, it may just increase the longevity and quality of life for many older adults around the world.

 

“Never too old to drum! Harry & Betty - 98 & 101 years old.”7

References

  1. Smith, C. , Viljoen, J. , McGeachie, L. & (2014). African drumming. Journal of Cardiovascular Medicine, 15 (6), 441-446. doi: 10.2459/JCM.0000000000000046.
  2. About POUND® - The Rockout Workout. POUND. (2021, May 10). https://poundfit.com/about/.
  3. World Health Organization. (2018, February 5). Ageing and health. World Health Organization.https://www.who.int/news-room/fact-sheets/detail/ageing-and-health#:~:text=Common%20health%20conditions%20associated%20with,diabetes%2C%20depression%2C%20and%20dementia.
  4. Fancourt, D., Perkins, R., Ascenso, S., Carvalho, L. A., Steptoe, A., & Williamon, A. (2016). Effects of Group Drumming Interventions on Anxiety, Depression, Social Resilience and Inflammatory Immune Response among Mental Health Service Users. PLoS ONE, 11(3). https://link.gale.com/apps/doc/A453471344/AONE?u=lom_umichflint&sid=summon&xid=2ee5752a
  5. Miyazaki, A., Okuyama, T., Mori, H., Sato, K., Ichiki, M., & Nouchi, R. (2020). Drum Communication Program Intervention in Older Adults With Cognitive Impairment and Dementia at Nursing Home: Preliminary Evidence From Pilot Randomized Controlled Trial. Frontiers in aging neuroscience, 12, 142. https://doi.org/10.3389/fnagi.2020.00142
  6. Tabei, K. I., Satoh, M., Ogawa, J. I., Tokita, T., Nakaguchi, N., Nakao, K., Kida, H., & Tomimoto, H. (2017). Physical Exercise with Music Reduces Gray and White Matter Loss in the Frontal Cortex of Elderly People: The Mihama-Kiho Scan Project. Frontiers in aging neuroscience, 9, 174. https://doi.org/10.3389/fnagi.2017.00174
  7. Never too old to drum! Harry & Betty - 98 & 101 years old. (2019). Northern Michigan Drum Village. https://www.nmidrum.org/workshops/2019/5/29/national-senior-fitness-day-may-29th-independence-village.

 


How to Prescribe Exercises to Your Older Patients with Chronic Conditions

 

Do you feel intimidated by the thought of prescribing exercise recommendations to your geriatric patients with chronic conditions? If you don’t know where to begin, be sure to understand this: Any amount of exercise beats remaining sedentary. This holds true even when a patient’s health status interferes with attaining recommended goals.1 However, as healthcare professionals, we strive to provide effective, evidence-based treatment that is individualized to each patient’s needs. Frequent chronic conditions in the geriatric population such as arthritis, osteoporosis, and heart disease have specific exercise recommendations to improve physical function and symptom management.

The risk of developing arthritis increases with age, and roughly 49.6% of people 65 years or older report being diagnosed with this condition.2 The goal of exercise for individuals with arthritis is to enhance function and decrease levels of pain to improve overall mobility.3 Both land and aquatic based physical activity can increase mobility, muscular strength, joint flexibility, and reduce pain in patients with hip or knee osteoarthritis.4, 5 Starting with aquatic based activities can have a therapeutic and pain minimizing effect through reducing joint loading. As mobility is improved and pain is reduced, land-based exercises can be incorporated.5 No pool in your clinic? Educating your patients on the benefits of aquatic therapy can go a long way. Patients can use a community pool when available to increase tolerance during in-clinic interventions.            

An estimated 10 million individuals in the United States have osteoporosis, and on top of that, 34 million have low bone mass.6 Consequently, the elderly population accounts for 70% of all fractures sustained due to factors such as reduced bone density, impaired balance, and muscular weakness.7 Evidence exists regarding the benefits of resistance exercises in improving bone mineral density.8 Resistance training alone is beneficial, but try it in combination with impact-loading activities, which has been shown to have greater improvements in bone density than walking alone.8, 9 Aside from improving bone density, fall prevention is critical with these patients to minimize fracture risk. Incorporating exercises that improve muscular strength, core stability, as well as coordination and balance will help prevent future falls.10 Don’t underestimate the power of educating your patients on household fall prevention strategies such as removing trip hazards, keeping walkways well lit, and wearing comfortable shoes with good support, non-slip soles, and a broad heel.11

Heart disease continues to be the number one cause of death in the US12, and roughly 80% of those diagnosed are over the age of 65 years old.13 Both moderate- and high-intensity exercise programs are beneficial for geriatric patients with cardiac comorbidities with low risk of a cardiovascular event.14 More recently, high-intensity interval training has also been recognized as a safe alternative for older adults with heart disease.15 Exercise can also improve mental health facets including quality of life, self-confidence, and anxiety. Regular exercise has favorable effects in decreasing major risk factors for heart disease including obesity, diabetes mellitus type 2, and hypertension.16 Your geriatric patients with obesity can benefit from a combination of resistance training and moderate-intensity aerobic exercise using a treadmill or bicycle. These exercises will help maintain muscle strength and increase energy expenditure to generate caloric deficits.17 Even better, aerobic exercise has been found to improve blood glucose control, insulin resistance, and cardiorespiratory function in patients with type 2 diabetes with additional benefits when combined with resistance training.18

As you can see, regular exercise routines can benefit geriatric patients with a variety of comorbidities. You can use exercise as both a prophylaxis and treatment for common musculoskeletal and cardiovascular disorders. In general, it is recommended that healthy, older adults perform at least 150 minutes of moderate-intensity aerobic activity and two or more days of resistance training per week as tolerated.18

 

References

 

  1. Lee PG, Jackson EA, Richardson CR. Exercise Prescriptions in Older Adults. Am Fam Physician. 2017;95(7):425-432.
  2. Barbour KE, Helmick CG, Boring M, Brady TJ. Vital Signs: Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation - United States, 2013-2015. MMWR Morb Mortal Wkly Rep. 2017;66(9):246-253. Published 2017 Mar 10. doi:10.15585/mmwr.mm6609e1
  3. Gaught AM, Carneiro KA. Evidence for determining the exercise prescription in patients with osteoarthritis. Phys Sportsmed. 2013;41(1):58-65. doi:10.3810/psm.2013.02.2000
  4. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:CD004376. Published 2015 Jan 9. doi:10.1002/14651858.CD004376.pub3
  5. Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016;3:CD005523. Published 2016 Mar 23. doi:10.1002/14651858.CD005523.pub3
  6. National Osteoporosis Foundation Report Finds Patient-Centered Care Is Key Element in Delivering High-Quality, High-Value Treatment. National Osteoporosis Foundation website. https://www.nof.org/news/national-osteoporosis-foundation-report-finds-patient-centered-care-is-key-element-in-delivering-high-quality-high-value-treatment/. Published July 29, 2019. Accessed May 31, 2021.
  7. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22(3):465-475. doi:10.1359/jbmr.061113
  8. Bolam KA, van Uffelen JG, Taaffe DR. The effect of physical exercise on bone density in middle-aged and older men: a systematic review. Osteoporos Int. 2013;24(11):2749-2762. doi:10.1007/s00198-013-2346-1
  9. Gómez-Cabello A, Ara I, González-Agüero A, Casajús JA, Vicente-Rodríguez G. Effects of training on bone mass in older adults: a systematic review. Sports Med. 2012;42(4):301-325. doi:10.2165/11597670-000000000-00000
  10. Bone Health Special Interest Group. APTA Geriatrics website. https://geriatricspt.org/special-interest-groups/bone-health/. Accessed May 31, 2021.
  11. About Osteoporosis. International Osteoporosis Foundation website. ttps://www.osteoporosis.foundation/patients/about-osteoporosis?utm_source=Enigma&utm_medium=cpc&gclid=Cj0KCQjwktKFBhCkARIsAJeDT0jp-ffmEwSte1J_t7nQPIBq_ytOJsAn-QsCXcVjn0uXEUp2TRifDakaAnFmEALw_wcB. Accessed May 31, 2021.
  12. Deaths and Mortality. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/fastats/deaths.htm. Updated April 9, 2021. Accessed May 31, 2021.
  13. Writing Group Members, Mozaffarian D, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association [published correction appears in Circulation. 2016 Apr 12;133(15):e599]. Circulation. 2016;133(4):e38-e360.
  14. Rognmo Ø, Moholdt T, Bakken H, et al. Cardiovascular risk of high- versus moderate-intensity aerobic exercise in coronary heart disease patients. Circulation. 2012;126(12):1436-1440. doi:10.1161/CIRCULATIONAHA.112.123117
  15. Dun Y, Smith JR, Liu S, Olson TP. High-Intensity Interval Training in Cardiac Rehabilitation. Clin Geriatr Med. 2019;35(4):469-487. doi:10.1016/j.cger.2019.07.011
  16. Kaminsky LA, Arena R, Ellingsen Ø, et al. Cardiorespiratory fitness and cardiovascular disease - The past, present, and future. Prog Cardiovasc Dis. 2019;62(2):86-93. doi:10.1016/j.pcad.2019.01.002
  17. Waters DL, Ward AL, Villareal DT. Weight loss in obese adults 65years and older: a review of the controversy. Exp Gerontol. 2013;48(10):1054-1061. doi:10.1016/j.exger.2013.02.005
  18. Nomura T, Kawae T, Kataoka H, Ikeda Y. Assessment of lower extremity muscle mass, muscle strength, and exercise therapy in elderly patients with diabetes mellitus. Environ Health Prev Med. 2018;23(1):20. Published 2018 May 17. doi:10.1186/s12199-018-0710-7

 


Every second of every day, an older adult (65+) sustains a fall in the United States. In addition, falls are the leading cause of injury in this age group.¹ Osteoporosis is a condition that causes bones to become brittle, which may increase the risk of a fracture. Typically, older adults have various impairments such as vestibular disorders, vitamin D insufficiency, medications, postural hypotension, vision impairment, foot/ankle pathology, and trip hazards that increase the likelihood of falls.² This can be extremely problematic for older adults who have osteoporosis. The best intervention for falls is prevention. By routinely screening elderly patients and taking preventative measures, falls and secondary complications can be prevented as a whole.

The prevalence of osteoporosis is a worldwide problem.5 Patients within the elderly population are more prone to having a reduction in bone density. Unfortunately, osteoporosis is on the rise within many countries. Researchers attribute this increase to elderly people living longer than before.5 It has been determined that a primary cause of bone density loss is through immobilization. When a patient is immobilized in a bed, they can lose just as much bone in a week as they would otherwise lose within a year.5 A way to prevent this bone density loss is to continuously emphasize the importance of strengthening exercises.

Individualized fall prevention programs have been found to reduce fall risk factors in older adults.³ One individualized program aimed at reducing difficulties in ADLs, improving self-efficacy, and reducing fear of falling in adults over the age of 70, and the program yielded positive results. Treatments were conducted by an occupational therapist to identify home trip hazards and provide environmental modifications. In addition, a visit by a physical therapist focused on balance, muscle strengthening, and fall recovery techniques. The results found that participants in the intervention group had improved ADL’s, self-efficacy, and a decreased fear of falling. ⁴

There are ways for osteoporosis to be avoided. Levels of osteoporosis prevention have been established as primary, secondary, and tertiary. Primary prevention techniques are meant to maintain bone density and minimize bone loss in the early adult years.5 While genetic factors can help to predict a patient’s bone loss, lifestyle changes can help to prolong having high bone density. Exercising and increasing the amount of calcium in a diet can be beneficial for maintaining bone density in elderly patients. Secondary prevention techniques focus on patients who have osteoporosis or osteopenia.5 This particular approach is emphasized for post-menopausal women and the elderly. Lastly, there is tertiary prevention. This type of bone loss prevention involves patients who have had previous bone fractures.5

            The rise of osteoporosis has increasingly become a worldwide problem that must be addressed. As patients are living longer, the need for lifestyle changes and promoting strengthening exercises has become evident. When a patient falls with osteoporosis, their impairments can be traumatic. There are a multitude of factors that can contribute to a patient falling, and thus giving patients the proper education needed for fall prevention can be crucial for their overall wellbeing.2 Various fall prevention programs have been created to help reduce falls, and these have been shown to be effective. The best intervention for falling is prevention education, and many lives will be saved around the world if health care professionals advocate for this.

Works Cited

  1. “Keep on Your Feet-Preventing Older Adult Falls.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 16 Dec. 2020, www.cdc.gov/injury/features/older-adult-falls/index.html.
  2. FACT SHEET Risk Factors for Falls, CDC, 2017, www.cdc.gov/steadi/pdf/STEADI-FactSheet-RiskFactors-508.pdf.
  3. Lord, Stephen R., et al. “The Effect of an Individualized Fall Prevention Program on Fall Risk and Falls in Older People: A Randomized, Controlled Trial.” American Geriatrics Society, John Wiley & Sons, Ltd, 14 June 2005, agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/j.1532-5415.2005.53425.x?casa_token=Z4pmioYntpcAAAAA%3AwwIgeJOIaBgHj4x6-Ex1MXU53SPG34NGYP4rCSsPgvFOBKQPQNXc8qViH8QVY8Cr7JwjPczaBsJzpKo.
  4. Chase, Carla, et al. Systematic Review of the Effect of Home Modification and Fall Prevention Programs on Falls and the Performance of Community-Dwelling Older Adults, www.researchgate.net/profile/Carla-Chase/publication/224878781_Systematic_Review_of_the_Effect_of_Home_Modification_and_Fall_Prevention_Programs_on_Falls_and_the_Performance_of_Community-Dwelling_Older_Adults/links/55cb78c908aebc967dfe174a/Systematic-Review-of-the-Effect-of-Home-Modification-and-Fall-Prevention-Programs-on-Falls-and-the-Performance-of-Community-Dwelling-Older-Adults.pdf.
  5. Posa G, Roka E, Sziver E, et al. Osteoporosis and the Role of Physical Therapy in the Different Domains. Journal of Osteoporosis and Physical Activity. 2017;05(01). doi:10.4172/2329-9509.1000190

 


 

Career, Interrupted: Tales From A Graduating PTA Class

2020 was, to put it mildly, a challenging year for all of us. But it was especially challenging for those in the PT field who were least-equipped to cope with its effects: the graduating class of 2020. Many of these students-turned-PTAs still find themselves un- and under-employed even as the pandemic is (hopefully) nearing its end. It is the intention of this editorial to shine a light on the plight of the newest generation of PTAs, who entered the field at what was arguably its most difficult (though some would say “finest”) hour. 

For the purposes of this editorial, I will be focusing on the experiences of graduates of Macomb Community College’s PTA program (of which the author is a member; go Class of 2020!). This is done partly in an attempt to limit the number of interviews necessary to write this article, since obtaining a core-sampling of the entire graduating class of the state of Michigan would be prohibitively difficult (especially for a beginning PTA who hasn’t made many professional contacts yet). It is also done out of entirely human self-interest: the young PTAs interviewed are the author’s friends, classmates, and peers; it is only natural to want to bring greater awareness to the plight of one’s cohorts, to hope for their professional success and to celebrate in sympathetic joy when they are able to overcome their first and greatest hurdle: starting their careers in the midst of a completely unprecedented medical emergency which has transformed human life and livelihoods on a global scale. I hope that the readers will forgive this small conceit on my part. And now, on with the show!

Q: How did the onset of the pandemic (and the subsequent quarantine) affect your final clinical rotation? How long did it take until your CI certified you as an “entry level” PTA? Do you feel that you missed out on anything?

  • Krissy Toth, PTA was one week into her final clinical when the quarantine went into effect. Unlike many PTA students, she was able to finish at her initial site, and got a full eight weeks out of it to boot. She felt she did get the full clinical experience, but was disappointed that social-distancing rules prevented her from job-shadowing the OTs or SLPs at her clinic. 

  • In the case of Adam Done, SPTA, the pandemic affected his classes at MCC, rather than any of his clinicals. So far, he’s only been physically present on campus four times this semester! His main complaint was loneliness: the pandemic led to decreased socializing with his classmates, which (combined with the plethora of distractions at home) sapped his emotional energy and made it more difficult for him to study.

  • It was a Friday morning when Angela Connor-Hildebrand, PTA heard about Governor Whitmer’s closing order during her morning commute to her clinical site. She finished her day working with special ed kids in the public school system, but because of the short notice, her last day was just like any other. That same day, MCC pulled all of its students from their clinical sites, citing concerns over students’ safety. Angela reported feeling satisfied with the backup clinical site she was eventually sorted into, saying it was “everything I thought it’d be, but I’ve got no real experience so I can’t say for sure.”

  • Ginger Holman, PTA, said she had been “really excited about the venue” of her final clinical: Henry Ford Hospital in downtown Detroit, Cardiopulmonary Unit. She was very disappointed when it was cancelled after just one week. Ginger reported feeling “very sad about it,” and opined that although PTA students were barred from the site, PT students were allowed to continue their clinicals there without interruption. After a few weeks of shuffling and nervous thumb-twiddling, Ginger ended up at Henry Ford Macomb, right on MCC’s main campus, doing inpatient rehab for just four weeks before “tagging out” with the next student.

  • Mike Cottone, PTA was just three or four days into his final clinical when the site (P.A.C.E.) told him they were unwilling to allow him (or any students) to return, citing concerns about the “novel coronavirus”. Mike eventually wound up doing his third rotation at the same VA Hospital where he had done his second rotation. Mike felt that it was unfortunate he couldn’t get experience with a wider variety of clinics, but was glad to be somewhere familiar and accepted that his options were kind of limited considering the pandemic. Due to social distancing requirements and patient reluctance, the outpatient clinic where he worked ran at only about 25% capacity for the remainder of his rotation there. Mike said he was only allowed on certain floors of the facility, and that he only saw one to three patients per day for weeks on end. He reported disappointment that he didn’t get as much experience as he’d hoped for from his third and final clinical, which was supposed to be the toughest and most intensive of all (at least in theory).

 

Q: How did the quarantine/pandemic affect your ability to study for the licensure exam? Did the pandemic add significantly to your stress?

  • Krissy Toth, PTA says that the quarantine actually helped her study, that she “had time to myself” without distractions (though it probably helped that she went to a friend’s cabin up near Port Austin where she could study in complete isolation four days a week). Krissy wound up passing the examination on her first attempt.

  • Adam Done, SPTA, didn’t need to study for the NPTE, but he did have classes and tests and exams, and the quarantine didn’t make studying for them any easier. Adam reported that the pandemic led to less socializing with his classmates, whom he only saw virtually for months on end, which drastically reduced feelings of camaraderie and esprit de corps. The quarantine also made it more difficult to study, because there were far more distractions at home (ranging from interesting books to dirty dishes) than at the local library or a coffee shop.

  • Angela Connor-Hildebrand, PTA stated that the quarantine definitely added to her personal stress levels. Ang’s grandma Mary Jean Connor], her surrogate mother and lifelong role model, passed away at the ripe old age of 84 just two weeks into the quarantine. As a result, Ang said that her mental health “was really bad, honestly” for some time afteward. Ang stated that she felt more depression than usual as a result, and was less able to focus on her studies. Luckily, her clinical at Neil King PT helped restore her headspace, and when she took the NPTE in October, she passed on her first attempt.

  • Ginger Holman, PTA responded that the pandemic undeniably added to her own stress as well, but for a different set of reasons. As her tweenage son adjusted to distance learning, Ginger found herself having to tutor him during the quarantine, even though she was supposed to be studying for her own exams(an experience which many parents can relate to). Ultimately, Ginger was forced to stop studying entirely and delay her licensure exam until October, like ~50% of her classmates.

  • Mike Cottone, PTA declared that, for him at least, the quarantine was “favorable, probably” for studying. Instead of taking the licensure in July as originally planned, he delayed until October so wouldn’t feel pressured. Mike said he didn’t start taking the practice tests until September, though. Mike said that the quarantine was “a little bit of a de-stressor, actually”, unlike house-hunting and moving during the lead-up to the NPTE, which he says was considerably more of a stressor for him than the pandemic itself. Lots of little things added up over the months of isolation, and because he didn’t know how things would work out, that manifested in him as having a short fuse and a constant feeling of being on-edge. Mike is happy to report that things have improved for him greatly since then: he and his fiancee Shannon are currently enjoying a happy and relatively low-stress lifestyle with their dogs on their home with acreage in Kimball, Michigan.

 

Q: How did the pandemic affect your job search? Did it take you a long time to find a job? Are you working in the PT field at all right now?

  • Krissy Toth, PTA had been a PT tech at HealthQuest before entering MCC’s PTA program, and went straight from her clinical to the clinic. She says she knew before graduating that she’d work at Healthquest, just not at which clinic in particular.

  • Adam Done, SPTA had also worked at HealthQuest since before entering the PTA program (just like his coworker Krissy). Having already put in five years at HealthQuest, he has a standing offer for employment there after he graduates in 2021.

  • After two years of studying, Angela Connor-Hildebrand, PTA struggled for many months to find employment in her chosen field. Despite graduating summa cum laude and applying for dozens of positions, for months she secured zero interviews for inpatient positions, not even PRN work, until just a few weeks ago when she finally found gainful employment with Neil King PT. It appears that Angela has a knack for graduating at just the wrong moment: the last time she matriculated was during the recession following the Gulf War. 

  • Ginger Holman, PTA discloses that the pandemic vastly decreased the number of jobs which were available to new grads like her, saying that she had even gone so far as to apply for a couple of PT tech jobs. Ultimately, though, that proved unnecessary: Ginger was able to secure a position with Tririga PT in Warren, where she has been happily employed since late February. 

  • Having passed the NPTE but feeling starved for cash, Mike Cottone, PTA went back to his old pre-PTA ways and took a job as a massage therapist, pending his licensure by the State of Michigan. Having a lead on a job prior to the NPTE, he parleyed his position as massage tech into a promise of a PTA position… but only when his license actually arrived. Though he passed the licensure exam handily in early October, it still took 11 to 12 weeks for his license to arrive (ironically, his temporary license from the state arrived just 48 hours before his formal license did, making the temporary license, in his words, “not a big help”).

 

Q: How has the pandemic affected your patients, and how you interact with them?

  • Krissy Toth, PTA writes that her patients have a variety of opinions on COVID, ranging from contempt to conspiracy-theories. What messaging does she use with patients who want to talk about China “inventing” the virus in a lab, or how vaccines (allegedly) cause autism? She usually “just smiles and nods, changes the subject, and politely shifts their focus back to task at hand. Krissy has stated in interviews that these days her clinic mostly helps counsel patients on the ergonomics of their home offices (offering advice on both setup and modification).  They treat lots of back and neck pain brought on by excessive screentime and insufficient exercise. Toth states that her clinic offers no telehealth visits; all treatments are still done IRL, and that they take extensive precautions when dealing with patients. For example, clinicians are only allowed 14 minutes of hands-on contact per patient, including all time spent within six feet of patients (even if they’re only holding the patient’s gait belt). These social distancing rules are enforced even for PT techs. All staff must undergo a mandatory 2-week quarantine if they test positive for COVID-19.

  • Adam Done, SPTA: writes that maintaining social distance during treatment is difficult, as is having to sanitize every surface even more thoroughly than usual. Mask-wearing is mandatory, of course, but they inhibit speech and can make communication with patients difficult, especially with geriatric pts who are often hard of hearing. Adam reports that his clinic has dealt with the pandemic by (among other precautions) limiting manual time to no more than 15 minutes per patient (down from the usual 20-35 minutes). If and when patients begin giving voice to conspiracy theories, Adam says he usually just tells them that “masks have been shown to help”, after which he tries to divert the conversation, pointing out that “you [patients] aren’t required to wear masks, but we [clinicians] are”.

  • Angela Connor-Hildebrand, PTA tells us that she is “eager to start and get experience, but still wary of the virus.” However, after all this time the virus is really a non-issue in her workplace; most of her patients are so “over it” that they have no interest in discussing the issue further than they already have in the last 12 months.

  • Ginger Holman, PTA: took several months after becoming licensed to find herself a job, but she is now happily employed at Tririga PT in Warren, Michigan, where she says “I love what I’m doing [and I’m] Hoping to suggest a few changes here and there eventually.”

  • Mike Cottone, PTA tells that his work is pretty steady right now. He’s seeing fewer post-surgical and MVA patients, and fewer high-functioning patients, but the latter is common for this time of year because lots of people haven’t met their deductibles yet. In general, Mike reports, his patients don’t downplay the pandemic, and he doesn’t even hear COVID mentioned on a weekly basis. Every table requires an extra wipe-down after each session, though, so there’s a financial side to the pandemic. So far, only one of his coworkers has lost a family member to the virus.

 

 


The term doctor originated in the early 14th century from the Latin word meaning “teacher.”  It referred to a group of theologians that had approval from the Roman Catholic Church to speak on religious matters and doctrines. Initially, the title was not associated with academics or health professionals. By the end of the 14th century, during the Renaissance, the term “doctor” was being applied to academics and medical practitioners.(3)

The name “Doctor” is given to anybody who has received a doctoral level degree from a university. This includes, but is not limited to:

Medical Doctor (MD)

Doctor of Osteopathic Medicine (DO)

Doctor of Philosophy (PhD)

Doctor of Physical Therapy (DPT)

Doctor of Dental Surgery (DDS)

Doctor of Dental Medicine (DMD)

Doctor of Optometry (OD)

Doctor of Pharmacy (PharmD)

Doctor of Podiatric Medicine (DPM)

Doctor of Nursing Practice (DNP)

Doctor of Occupational Therapy (DOT)

Juris Doctor (JD)

Doctor of Veterinary Medicine (DVM)

Doctor of Chiropractic (DC)

 The use of the title “doctor” for non-physician health professionals has been heavily debated. One should not use the title “doctor” if they are to be mistaken with a physician. This is especially important in hospital settings— if one is to use the title “doctor,” they should specify what type of doctor they are. This will provide transparency and eliminate patient confusion, ensuring patients know which professional they are speaking with.

Doctorate of Physical Therapy:

Doctors of Physical Therapy (DPTs) are movement specialists who focus on a non-pharmaceutical approach to reducing pain, optimizing kinesthetic function, and reduce the risk of falling. DPTs may work in outpatient settings, in hospitals, schools, nursing homes, home health, and other venues. Specialties in the field include orthopedics, sports, neurology, pediatrics, geriatrics, woman’s health, cardiopulmonary, oncology, and electrophysiology. Treatment interventions include therapeutic exercise, therapeutic activities, neuromuscular re-education, gait training, joint mobilizations, joint manipulations, soft tissue mobilizations, dry needling, blood flow restriction training, vestibular rehabilitation therapy, as well as others.

Physical therapy (also known as Physiotherapy) has been a doctorate level education since 1992, and as of 2017, there are 222 Doctorate of Physical Therapy programs in the United States. After completion of their doctorate, physical therapists must pass a state licensure and national board examination to clinically practice. DPTs may specialize in the profession through a residency or fellowship. There are 178 credentialed residency programs and 34 credentialed fellowship programs in the USA.(1) Physical therapy graduates appropriately use the title “doctor” as they fulfill all the requisites of a Physical Therapy Doctoral program.

            To earn the appellation “Doctor of Physical Therapy,” one must complete four years for a bachelor’s degree, three to four years of a doctorate, with an optional one to two year residency, and/or an optional one to two year fellowship.

The American Physical Therapy Association’s statement on the use of the designation “doctor” states:

"The American Physical Therapy Association supports the use of the title of 'Doctor of Physical Therapy' only for those physical therapists who have graduated from a DPT program. In order to provide accurate information to consumers, physical therapists who have earned a Doctor of Physical Therapy Degree (DPT) and those who have earned other doctoral degrees and use the title 'Doctor' in practice settings shall indicate they are physical therapists. Use of the title shall be in accordance with jurisdictional law."(4)

In other words, DPTs may use the title “doctor” and must indicate that they are a physical therapist. This gives clarity to patients as to which specialty their doctor practices. In hospital settings, however, it is more likely that patients may confuse a physical therapist with a physician. Therefore, physical therapist’s use of the title is discouraged in hospitals.

 With the exception of DPTs who attend to military personnel, DPTs do not prescribe medications; however, they do prescribe therapeutic exercises, medical equipment, and adaptive equipment. Furthermore, all states in the USA have direct access, allowing a patient to seek treatment from a physical therapist without referral from a physician. It’s especially important to visit a physical therapist if one has any pain, injury, and/or is at risk of falling. This statement is an abrupt departure from advocacy to advisory.

 The rigorous training completed by Doctors of Physical Therapy should be comforting to patients. Through the use of thorough evaluations, DPTs are well versed to diagnose and properly treat patient’s ailments.

Misinterpretation for patients is discernable in the absence of specificity of healthcare doctors. It behooves the medical professions and society to refer to medical doctors as “physicians,” or by their specialty; internist, cardiologist, pulmonologist, endocrinologist, etcetera. This will break the cycle of patients thinking all doctors are physicians, because as shown above, there is a diverse number of doctoral professionals.

References

“Accredited Schools Directory”. Aptaapps.apta.org.

Sears, B. (2020, June 29). Gait Training Exercises In Physical Therapy. In Very Well Health. Retrieved from https://www.verywellhealth.com/gait-training-in-physical-therapy-5069884

The History of 'Doctor' (n.d.). In Merriam-Webster. Retrieved from https://www.merriam-webster.com/words-at-play/the-history-of-doctor

Transition DPT FAQs (2019, December 1). In American Physical Therapy Association. Retrieved from https://www.apta.org/your-career/career-advancement/postprofessional-degree/transition-dpt-faqs#:~:text=APTA%20has%20a%20position%2C%20Use,graduated%20from%20a%20DPT%20program.

 


Change is inevitable. Everything must change. Change is the only constant. These commonly used expressions hold some truth, and in considering our profession’s evolution as we celebrate the Centennial, they have got me thinking about our collective future. What will physical therapy look like? What should it look like? What must it look like? There are three potentially very different answers to these questions. We only win if the answer to all three is the same. We only win when we do it together, as a unified association.

We have some existential threats that will shape who and what we become, and we must deal with those threats successfully if we are to thrive. The ones I want to focus on here are value-based payment and diagnosis. I believe these two issues to be key drivers of many other related issues including the worsening student debt-to-income ratio, our lack of workforce diversity, our professional identity, and physical therapists being the providers of choice.

Regarding value-based payment1, we are clearly not thriving on procedure-based, fee-for-service payment models. Payers are not offering substantial increases in payment, even if we demand it.  Gone are the days that we will be paid for the volume of service provided, especially when it is not linked to outcomes. I believe that the only way we will be able to see increases in payment is by clearly measuring and demonstrating our value. This requires systematic measurement (and reporting) of outcomes…patient satisfaction, patient-reported outcomes, objectively measured functional performance outcomes, and down-stream cost savings with regard to reduced imaging, surgery, opioid use, emergency department visits, hospitalizations, and specialist consultations. When we demonstrate our value, we have the best chance at increasing payment for our services. Salaries can increase. Student debt-to-income ratios improve. PT school will be more affordable and a more attractive career option to a greater diversity of people. The diversity of our workforce can start to reflect the diversity of the communities we serve.

Regarding diagnosis2,3, I have been following with great interest the ongoing discussion about diagnostic labels and their relevance to not only our professional identity, but also to research and payment policy. There are no easy answers here, and as Dr. Deusinger puts it, this is a “wicked problem.”3 But we must confront it. What makes me cringe is the high probability that a single patient could see 5 PTs and come away with 5 different diagnoses. This is true of all PT clinical settings and specialty areas, but is especially true in the outpatient orthopedic world. Without having a single, unified, data-driven diagnostic classification system that is universally taught in entry-level professional education, we rely upon a continuing education industry to sell competing approaches and certifications to licensed clinicians for how to diagnose and treat patients. Not surprisingly, we can have 5 or more different diagnoses for the same problem in a single patient depending on what treatment approach the clinician “follows” and “believes in.” The path forward is indeed “wicked”, but if we do not develop even some semblance of a research-supported universal classification system, how can we assure payers, policy-makers, and patients that we can consistently and predictably deliver on our brand promise and be the provider of choice?

 

Predicting the future is difficult. Ignoring history is condemnation. Since 1921 our profession has faced many existential threats and wicked problems. As we reflect on the past 100 years, let’s remember the single constant: It is only as a group of professionals unified by OUR professional association that we have succeeded. The next 100 years will be no different. Here’s to the start of our second centennial!

 

1 Dianne V. Jewell, Justin D. Moore, Marc S. Goldstein, Delivering the Physical Therapy Value Proposition: A Call to Action, Physical Therapy, Volume 93, Issue 1, 1 January 2013, Pages 104–114, https://doi.org/10.2522/ptj.20120175

2 Shirley Sahrmann, Defining Our Diagnostic Labels Will Help Define Our Movement Expertise and Guide Our Next 100 Years, Physical Therapy, , pzaa196, https://doi.org/10.1093/ptj/pzaa196

 

3 Susan S Deusinger, PT, PhD, FAPTA, Robert H Deusinger, PT, PhD, Achieving Diagnosis-Based Practice: A Wicked Problem in Physical Therapy. On “Defining Our Diagnostic Labels Will Help Define Our Movement Expertise and Guide Our Next 100 Years” Sahrmann, S. Phys Ther. 2020 https://doi.org/10.1093/ptj/pzaa196, Physical Therapy, , pzab005, https://doi.org/10.1093/ptj/pzab005

 

 


The Underrated Benefits of APTA Michigan Membership

I’d like to preface this article by saying that there is no single best reason for maintaining a professional membership in ATPA Michigan (APTA MI). Membership provides a list of benefits that is long and varies from person to person—and that’s okay! Today, however, I’d like to take a little time to recognize the membership benefits that I consider to be unsung heroes. The benefits, in my humble opinion, often go uncelebrated. The benefits that are typically overshadowed by some of the other, more tangible benefits our professional association provides.

If there is one thing that I have learned in the past three years by volunteering for APTA Michigan’s Membership Committee, it is that each person measures the value of our professional association differently, and one person’s reason to be an APTA MI member may be completely different than another’s. In full disclosure, my data on this subject is purely anecdotal; however, often times when I ask individuals to discuss the aspects of their APTA MI Membership they find most valuable, the most common responses I hear are things like:

1. Access to content and resources.

3. APTA MI conferences and events.

4. Networking opportunities with other professionals.

Don't get me wrong, I love and appreciate these benefits too! I’ve utilized my unlimited access to content and resources, like PTNow, Rehab Reference Center, and APTA Article Search on countless occasions. I enjoy member discounted rates for registration at conferences and continuing education courses. More than once I have used the network of professional relationships that I’ve built through this association to my advantage. Moreover, the place I’ve found within the APTA MI has helped me to feel like I’m engaged in my profession and a part of something larger than myself.  I am grateful for these aspects of my membership and I understand why other members enjoy these benefits too.

Membership benefits like access to resources, attendance at conferences and networking opportunities are the aspects of APTA MI membership that we are most readily able to see, experience and utilize for ourselves. Today, however, I want to recognize three benefits that sometimes seem to go on behind the scene. These benefits may be less visible and less palpable to us than other benefits, but they are in no way less important:

  1. Payment
    1. While you are enjoying the access to resources, conference, and networking opportunities, your membership dues are working to advocate for our profession’s best interests by allowing APTA MI to sit at the table with third party payers such as BCBSM and CMS to ensure that their policies are consistent with the current professional standards of practice and Michigan state law.
  1. Legislative Advocacy
    1. Additionally, your membership dues are working to give our profession a unified voice, by allowing APTA MI the ability to analyze legislation to ensure it reflects our current scope and standards of practice on both a state and national level.
  1. Physical Therapy Identity
    1. Finally, your membership dues are working to develop our profession’s identity, by allowing the ATPA MI to promote recognition of the breadth and depth of physical therapy services to the public, our consumers and other healthcare professionals. 

I know these benefits may not always be something that members are able to directly see or experience as they materialize. Oftentimes, the individuals who make these benefits possible are silently at work while we are busy tending to our daily lives and focusing on our own practice. However, it is still important to acknowledge that these aspects of our membership do in fact have a direct impact on our professional practice. As a profession, we all benefit as a result of the continual efforts of our professional association to represent our best interests. Together our membership in ATPA MI creates a unified front when it comes to issues related to legislation, payment and our professional identity, which is something that as individuals we could never hope to accomplish. Once more, establishing a unified profession is one benefit that I think we can all agree is truly priceless.

So, before I leave you today, I hope you take a moment to reflect on and maybe even reconsider the value you see in your APTA MI membership. While I know that as members, we will continue to enjoy the conferences, the resources and the networking, I hope that we can also give some of the other ATPA MI member benefits the recognition that they truly deserve.

 

 


When the world took a turn with Covid-19, we were ready to think on our feet and adapt to our conditions in order to be successful. In PT programs across the nation, we saw adaptations such as reduced class size, hybrid learning, reduced lab hours, full PPE in labs, and limited lab partners in PT classes. Not only did we make rapid accommodations, we did so in a way where we remained confident that students were clinic ready. This resilience in the face of adversity is a testament to what we are capable of as a profession.

Covid-19 is not the first situation in which this resilience has been warranted; however, it is perhaps the first situation where it was necessary. For various religious or cultural reasons, people have requested accommodations. Sadly, many have been treated as though their accommodations were impractical or a hindrance to learning. Today we might see those barriers as largely self-imposed. As an observant Muslim woman, I have firsthand experience with this. I requested religious accommodations in PT school, which included having a privacy screen and not having the men in my class work on me during lab. I made sure to be clear about these accommodations from the first day of class. I have never been hesitant to speak up, and I have advocated for the accommodation of Muslim students at the state and national levels. Despite going in with a message of clarity regarding my religious accommodations, I realized quickly that I could not lose vigilance in the advocacy for my rights. To me, my situation was simple. To others, it was a hassle that was at most tolerated. One memorable event occurred in class, when I realized I was mistakenly paired with a male partner. I switched partners with the person next to me and proceeded with my learning.  An instructor noticed and called me out after class. I was told that I was unprofessional in my conduct and that my behavior was burdensome to the class. The instructor’s words weighed on me. I felt tolerated, not embraced or appreciated for my differences. Reengaging with learning is always difficult after such situations, and this was just one of many I have faced in school and in clinics. Asking for help becomes harder and finding the motivation to continue facing the same situation each day feels impossible. Covid-19 is a testament to how much we are capable of and how much better we can do. How many students were in situations like my own? How many did we inadvertently deter from becoming PTs due to the perception that we were not eager to accommodate them? How many hesitated to speak up about cultural, religious, or other accommodations because it did not seem the profession valued them enough? I am not speaking in hypotheticals. I was that student, and I have met these students. Most recently, I was asked by a new student if requesting an accommodation would “rock the boat” too much and impact her professional career.

Let us not underestimate ourselves in the future. While we hope Covid-19 ends sooner rather than later, this newly discovered creative ability should be something that is continued long after this virus is gone. It should continue as an essential element of our profession and should be applied to better treat, accommodate, and foster the success of minority students. It is a strength we should embrace today and in the future.

 


In the world of an acute care therapist working in a large metropolitan hospital, we live day to day knowing that we will not be able to provide treatment to the number of patients who need our services because of high patient volumes.  We spend most of our time trying to figure out some sort of priority list that tells us which patients are going to make the cut for treatment.  New evaluations, patients returning home, patients who need rehab placement.  Who needs us the most?  It’s the question that physical therapists in acute care struggle with every day.  Did we help the right patient at the right time and were we the right provider? 

Helping people to understand the role of the acute care therapist can also be a daunting task.  No, we aren’t just here to provide a discharge recommendation.  We aren’t just the resident lift team for the hospital either.  We are skilled professionals, experts in mobility and regaining function in the presence of disease, musculoskeletal impairments and critical illness.  We are here to help a patient regain their independence.  We are here to listen to what their goals and needs are so we can help them achieve those things.  Both of these issues are on the forefront in the life of acute care therapy on a regular basis, but then came Covid-19…

In the midst of the chaos trying to accommodate the significant number of patients with Covid-19 in a hospital right in the epicenter of Michigan’s coronavirus outbreak, we began to see our volumes for therapy decline.  Decline is probably an understated way of describing it.  It was more of a drastic, mind blowing decrease in the number of patients on our schedules.  Our ICU’s, where we have a robust early rehab program were filled with patients so sick, the only goal was survival.  Therapy wasn’t even a thought in those initial phases.  General practice units were being turned in to ICU’s to accommodate the volume of critically ill patients we were admitting.  For the first time in an extremely long time, we were needing to completely restructure our department to be able to utilize our staff.  We deployed some of our staff to a prone team for Covid-19 patients. Others became “screeners” and worked on identifying patients that would benefit from therapy services so discussions could be had with physicians to place orders for a therapy consult.  It was a whole new world for us, however it led us to the path that we had always wanted to be on. 

With this new world came a new sense of empowerment for therapists. Having the ability to see the patients who truly needed skilled therapy services daily.  After all, this was potentially the only therapy they were going to receive related to their hospitalization.  There were so few rehab facilities accepting patients, especially patients with Covid-19 after hospital discharge.  Physical therapists getting the chance to do what they do best- help a person reach their full potential for functional independence and return home.  The outpouring of appreciation from patients so energized to receive therapy in the hospital so frequently was invigorating during a period of crisis that felt like it could swallow us whole.  These patients were isolated. There were no visitors, minimal contact with hospital staff to prevent over exposure, and no going to the hallway.  They were isolated to 4 walls with the door closed.  The therapy sessions were a bright spot for these patients.  They were eager to work.  They were eager to get better and stronger.  They were eager to return home.  For once we didn’t have to justify why we couldn’t see a patient daily because our time needed to be divided by an enormous number of patients.  We had the ability to do it and it felt right.  It was the right thing to do - for the right patients. And we were the right providers.

What’s more is that the absence of therapy for our severely critically ill ICU patients, made other healthcare providers realize just how important physical therapists were to a patient’s recovery.  Upon our return to the ICU’s, we were greeted with “we missed you,” or “I’m so glad you are back working with these patients.”  We weren’t just there for a discharge recommendation or to lift someone who couldn’t be moved by the nursing staff.  They wanted us there for our ability to get patients stronger and assist in their overall healing process.  Our impact in those ICU’s was brought to light by Covid-19.

While Covid-19 will leave a long-lasting impact on us all, if we had to find a silver lining in the trauma and sadness, this would be one of those things.  When you hear about your co-workers contracting Covid-19, being put on a ventilator or worse, the look of gratitude on a patients face is just the thing you need to keep you going when you feel like you can’t take another step.

 

 


Into the Unknown

If you started belting “Into the Unknown” like you are Idina Menzel (Elsa from Frozen) after reading the title, don’t worry you aren’t alone. While for Elsa, the song was in response to a mysterious voice beckoning her into the unknown, perhaps the events of 2020 are calling us and our profession to a similar journey of self-awareness and discovery.

Has anyone ever asked you ‘where do you see yourself in 5 years?’ I think I am pretty safe to say that we have all been asked this question at least once, and that most of us NEVER envisioned 2020 going the way that it has. That being said, as I reflect upon the impact the COVID-19 pandemic and the Black Lives Matter movement had on this year’s APTA House of Delegates (HOD) meeting, I am reminded that we are a profession that has evolved and thrived on forging into the unknown. We address the necessities of our society by building upon our knowledge and skills, utilizing new technologies, pushing for educational advancement and by traversing into new clinical environments and specializations. Consider how far we have come over the past almost century. We have evolved from being an exclusively female profession of rehabilitation aids helping war veterans and polio patients to now diversifying our membership, expanding our presence in a multitude of practice specializations, achieving doctorate educations, and taking on more practice autonomy, to highlight a few. While we should both celebrate and be humbled by our achievements, let’s not stop here. If we were to ask ourselves ‘where do we see our profession in 10, 50 or even 100 years?’, what do we envision for ourselves? Where do we go from here? 

What does it really mean to be a physical therapist or physical therapist assistant? What makes us stand apart as a profession? Why do we invest so much of our time and energy on researching, advocating and providing the best care for each patient? What issues would we unite around and fight for?

Take a moment- I am sure you have come up with at least one fundamental issue that you would want to have changed or improved upon. Maybe it’s the education cost to reimbursement ratio, maybe it’s the burnout from lofty productivity goals and endless documentation, maybe it’s the wish to be an “essential” healthcare worker; whatever “it” is, I challenge all of us to step out from behind our documentation, differing environments and social media feeds to actively question the status quo and start a collective roundtable dialogue, invite all members of our profession to participate. The steps forward for our profession start now. Let’s not just #choosept, but let’s #prioritizept. Let’s start the new century as a unified front with a collective vision as we enter into the unknown. 

 


Note:  APTA Michigan supports all candidates, regardless of political party affiliation, who are supportive of issues important to our profession and patients we serve.

Many of you have heard me talk about the importance of civic engagement. I am currently running for State Representative in Michigan’s 60th House District and am in a competitive primary which takes place on August 4. While I highly encourage physical therapists and physical therapist assistants to consider running for office (we need more of us making decisions at all levels of government!), I wanted to discuss a few political options that can make a difference for our profession.

First, NOW is the time to consider volunteering, donating, and helping with a campaign and candidate you believe in. Trust me, candidates will REMEMBER those volunteers who spent time making calls, texting, lit dropping, putting up yard signs and giving of their time to help the campaign. Of course, monetary donations are also needed, but there is nothing like volunteering to make an impression with a candidate and future lawmaker.

Second, consider applying to serve on a city, county, or state advisory board. There are many – some to consider include Public Health boards, environmental boards, school boards, and planning commissions.

Third, use your social media platforms to help encourage people to vote for candidates you think are physical therapy friendly and will help promote our issues.

Last but not least, vote, AND take someone with you to the polls or encourage your friends, family, and neighbors to vote. And if you have students in your workplace, encourage them to get registered and vote.

Also, please consider thanking a candidate for running. Whether they win or lose, being in the public eye is a difficult endeavor. Few reach out and say thanks. Again, you will make a difference and stand out by sending a note of appreciation to your favored candidate after the election.  Include your business card and offer to be of assistance with any health-related legislation or issues that may arise.

Julie M. Rogers, PT

Candidate for State Representative, 60th House District

julie@juliemrogers.com

 


The Golden Retriever

                A long time ago in some undergraduate psychology class I vaguely remember taking a personality survey designed to best match an animal to your personality characteristics. One look at the title above and you can guess what mine was. My qualities of dedication, focus, playfulness, and loyalty forever cemented my place as…well a dog apparently. In all seriousness though I should have realized these qualities for what they were at that time, a prediction of my future role as a clinician and a leader.

                There is a reason golden retrievers are one of the preferred breeds as leader dogs for those with vision impairments or disabilities. This breed is caring when needed, but also committed and focused to accomplish a particular task and ensure safety. Golden retrievers are loyal beyond all else and exhibit a playful yet modest demeanor that cements them as a quiet leader. I possessed these similar qualities years ago and somehow have refined them over the years to carry over into my personal clinical and leadership style. How do you refine qualities similar to a leader dog and employ them in the world of physical therapy you ask? Well, let me try to explain.

Before I delve into this rabbit hole let me first say that this leadership style is by no means the best and is certainly not for everyone or every setting. This also is not intended to be a self-help guide; this is merely how I have evolved to think about leading over the last several years. One of the main reasons golden retrievers make good leader dogs is they listen. They patiently wait for a signal, noise, or action from their master to then quietly initiate a response. A quiet leader is quiet because they listen first. Listening to the verbal and non-verbal signals presented by others will enable you to understand their emotions, motivations, and fears. When people know they are being heard it helps diminish their stress reaction and introduce real communication.

Second, quiet leaders just like golden retrievers are genuine. A quiet leader believes in who they are and what they do. Confidence is equally important whether leading a person with a visual impairment across a busy street, or leading a department during a global pandemic. Any amount of hesitancy certainly will result in disaster, so the quiet leader calmly picks up the leash and their head and marches out. This does not mean you are always headed the right direction (even dogs get this wrong), but it means the people behind you will follow even if they are not sure because they trust you. This trust is not built solely on experience or skill, but on loyalty, focus, and dedication.  I have spent a lot of time over the past few years NOT reading leadership books. Instead, I read books on vulnerability, late bloomers, and the power of introverts.  These topics help me understand myself better as well as understand how to think the best of the patients and staff I work with. Knowing people and being intuitive help me motivate my patients and those I work with to get the best results.

Lastly, a quiet leader much like the golden retriever does not necessarily have to be quiet or silent.  The quiet is not a reflection on sound but more so calm, simple, and restrained. When danger lies ahead, the golden retriever might let out a short but emphatic bark to warn of an incoming threat. When necessary, even a quiet leader will give succinct direction, or speak forcefully to best advocate for their cause.  This action is only used though when imminent risk is present and immediate direction is needed. The rarity of utilizing your words in this way lends weight to them. When I bark, people generally listen because they know it must be important.

Well there you have it, my life as a leader dog. Ironic as it may seem, I really feel this is the best way to describe the style of quiet leadership. Even if you’re not officially in a leadership position, I can guarantee you that everyone is a leader to their patients. You are guiding them away from pain, towards recovery, strength, and independence. There are a lot of books on leadership, and I really could tell you I have not read that many of them. What I can ask you though is to think of people who you admire and follow, how do they inspire you? Now think of that golden retriever, who listens, is confident, calm, direct, and patient. I would follow that leader into a busy street, or a new project, or a global pandemic. Be the quiet leader that sets an even tone every day. Be a leader that listens first and waits patiently for a sign to act. Be the leader that is genuine and confident enough to be calm amidst chaos. Be the leader that is the role model for the ideal member of the group. Why not be a golden retriever?

               

 


Riding the Pine

Not familiar with the phrase? It is an expression in sports that refers to being on the bench…being on the sidelines and not having the chance to get in the game and contribute to the team’s effort.

I have found myself thinking a lot lately about my days playing basketball in high school. Those who know me may be shocked to know that yes, indeed, I played varsity basketball in high school. At 5’8 ¾” first thing in the morning when my intervertebral discs have been hydrating all night, “basketball player” is not the first thing that comes to mind when you think of me. And by “play basketball”, I really mean lots of playing in practice. And even when I got to play during the last few minutes of those games when we were crushing the opposing team, I missed a lot of shots and had several turnovers. There was a reason I was a pine rider.

So I got good at helping my teammates in practice to prepare for games and cheered them on, especially when the game was close or when we were losing. “Let’s go Blue!”  But I spent a lot of time riding the pine and enduring the frustration and disappointment that goes with it. I thought those days were long behind me.

Then came COVID-19.

My full-time employment is as an Associate Professor in a DPT program, and I try to squeeze in as many clinical hours as I can in my favorite practice setting: cardiothoracic critical care. I am blessed to have my academic office across the street from a large academic quaternary care cardiovascular hospital that offers the full complement of heart/lung transplant, mechanical circulatory support, and other services.

For those who know how little cardiopulmonary content I got in PT school and the dumb cardiopulmonary mistakes I made early in my practice, you would be surprised to learn that I now consider myself a “critical care PT”. And now, just as in high school, during the big COVID-19 “game”, I am riding the pine.

But here is where the COVID-19 pandemic and high school basketball are different. COVID-19 is not a game. It is life and death, and is leaving a wake of destruction in patients’ lives and the lives of health professionals. I am not in the game not because of lack of skill (or height), but because the pandemic has decimated employment opportunities for health care providers. Redeployment of full-time clinical staff means the part-timers like me aren’t (yet) needed.

So I sit on the sidelines and ride the pine. I am cheering for my friends and colleagues on the front lines, and am supporting them where I can. But I feel left behind. Powerless to make an impact on my community and help patients in need. Worried about the health and safety of my comrades in the game. But this is not a game- it is war.

I signed up on the State of Michigan volunteer provider portal. I signed up as a respiratory therapist as PTs weren’t yet listed. I volunteered to take advantage of Executive Order 30 allowing PTs to serve as respiratory therapist extenders. Over three weeks later I finally got the call to go to the East side of the state to help. I started the on-boarding process. I jumped off the bench, tore off my warm-ups, and ran to the timer’s table and took a knee waiting for the next stop in play.  Excited, nervous, but ready.

Then I got called off. Their needs changed. Back to the bench. Disappointed. Frustrated.

But here’s the thing that makes it all OK: My impact was made years ago. So many of my former students and who are now my dearest colleagues have stepped up and are leading. They are warriors.  They are fighting. They are making the difference. “Let’s go PT!”

The next group of first year DPT students are taking my cardiopulmonary course this summer. It is another opportunity to further develop our profession’s capacity to manage patients with complex cardiovascular and pulmonary conditions across the continuum of care. I hope they realize just how seriously they must take this course. It is life and death. These are skills they need. That our country needs. COVID-19 may be over by the time they are licensed, but they need to be ready for the next pandemic.

I have concluded that I am not riding the bench at all. No, I am fighting the good fight and am a critical part of the war effort. It is Rosy the Riveter kind of stuff, doing my part on the Homefront during a world war to prepare those on the front lines.

My clinical time will come. OUR time will come. For all of us not working clinically right now, health care WILL rebound.  Our country’s health care needs have not gone away. They have gotten worse. We will ALL be needed. Riding the pine sucks. But this game won’t be won until we are all off the bench and playing. This is a game we can’t lose, won’t lose, and we will all play our part. Get ready to tear off those warm-ups…

 


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