Episode 1545 - Assessing physical activity & behavior change in older adults

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses how healthcare providers can learn to assess patients' readiness to change when becoming more active, barriers they perceive to exercise and confidence in implementing a regular exercise program. Alex challenges providers to become a "guide to self-efficacy" with patients to increase their regular physical activity.

Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION

00:00 INTRO

What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're sure to use the code ICEPT1MO when you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show.

01:33 ALEX GERMANO

Good morning, Instagram. Welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today's segment of Jerry on ICE. My name is Alex Germano. I'm a member within the older adult division. We are going to talk about a recent article that came out talking about how to address inadequate physical activity in our patients, especially older adults. The older adult division continues to charge across the country this fall with courses in Charlotte, North Carolina, Fort Collins, Colorado. That's happening this weekend. You can catch us in Oklahoma City, Bellevue, Washington and Falls Church, Virginia to round out September. Head to the PT on ICE.com website to learn more about our current course offerings. It does not seem like we're slowing down coming into the end of this year.

02:31 INCREASING PATIENT'S PHYSICAL ACTIVITY

I know it seems a little lame to come on the podcast and talk about increasing our patients' physical activity clinically. I mean, I say this is a little lame because I think it's something like we're like, duh, we all know. We need to get our patients more physically active. And so it doesn't seem like the coolest thing we can talk about if it's a problem we all know about. But I thought this article added a lot of value to this conversation. Clinically I've really gotten to this point as a therapist where I believe that most of my patients' ailments, their balance concerns, the unsteadiness they have, the lack of endurance they have, the lack of strength could all really be fixed by joining a gym or performing some type of meaningful fitness in their lives. I have really begun to embrace and step into this role of being a guide to their land of fitness for my patients. And I do care about the reason I'm there and trying to work through that with them. But really the ultimate goal in the back of my mind the whole time is how can I lead this person to meaningful fitness for longer durations? Because I know that my physical interventions are not going to stick around too long if the only thing that they're doing for physical activity is physical therapy or occupational therapy. Now because this is the way I approach my patient care and sometimes I'm all by myself out there in the world doing home visit, I really thought that every physical therapist out there was trying to increase their patient's physical activity. And I think I'm a little blinded by the community that I'm a part of, ICE, and that we're probably all trying to do this. So I just thought every physical therapist is out there really trying to do this thing and everyone's going to be super bored by this conversation until I saw the statistic in this paper that despite 91% of older adults over the age of 65 not performing recommended activity guidelines, 91%, which is costing the world $53.8 billion a year, 50 to 75% of healthcare providers are not assessing and addressing inadequate physical activity in their patients. 50 to 75% are not addressing physical inactivity. And I thought to myself, oh well let me look at the studies that they're citing for these statistics because clearly physical therapists or occupational therapists are definitely addressing this. They probably lump together all these healthcare providers. No, most of the studies they cited for the statistic were involving physical therapists or other rehab providers. Yikes, mind blown. This is significant. And I think a lot of us are trying. We're probably trying. We are making some of these light suggestions for home exercise program. We tell people to break up sedentary behavior and sedentary time. But how often is that really working? How often does that patient go off to join a gym? How often do they start seeing the personal trainer? Do they start telling you every time you come, I am doing all of my home exercise? Honestly, not very often. So it's not maybe our lack of trying, but rather the way we're trying to approach this conversation is what's off about how we're trying to solve this problem. So this article that I am referencing, which will be in the links on this Instagram page, suggests that we might not be advocating for physical activity well due to a few factors. It could be our lack of knowledge or confidence on how to assess and address inadequate physical activity. It could be an uncertainty on how to use behavioral change techniques in clinical practice.

04:05 LACK OF PHYSICAL ACTIVITY AWARENESS

So the first part, how do we get more comfortable and confident in assessing and giving our patients physical activity recommendations? At the Institute of Clinical Excellence, you've heard it a million times. We do it ourselves. We walk the walk. We be about it. We can't say this enough, right? By having a solid foundation of our own exercise program, you're going to be much more convincing, much more inspirational to your patient whom you're trying to get to the land of fitness. Now I will admit sometimes though, I'm going to be and not worry about this. I don't think that this is, I think this is important that we're this way, but it's also important that we remember what it was like to not be fitness forward at all because having this strong personal practice and exercise can be detrimental. I am on vacation and I, when I'm on vacation, I love to exercise. Like love it. I got out there for a run this morning because we're coming up to our marathon and I wanted to get out there, got a good run in. I love to work out because on vacation I have extra time. I'm not in a rush to be in the gym early and get out of there early. So I love it.

07:21 EXERCISE AS A CORNERSTONE

A lot of my patients though report that exercising on a vacation is like absolutely not going to happen, right? It's like, it's so easy they're not going to be able to do it. And like I was thinking about like, why do I exercise on vacations? Because it means so much to me and I really know and appreciate exercise in my life, right? This is the curse of knowledge that I have. I know how good exercise is going to make me feel for the rest of my days. My patients do not feel that way. Dustin Jones talked about this actually a number of years ago talking about the curse of knowledge. I know how good it feels, how easy I can fit it into my life even in exceptionally busy times. We don't remember what it's like to be that newbie. And it's a huge excuse I see for my patients and I almost want to laugh when I make patients tell me they don't have enough time to exercise, especially knowing they're retired. They're not really having much to do around the house. Like most of their chores are kind of outsourced to other people and like as a new, like a newer mom, right? Like I have a one and a half year old and I've worked multiple jobs. Like sometimes I feel like I'm barely hanging on. Exercise remains a staple in my life. I could sit on my high horse and tell them I'm so busy and I still can fit in five days of exercise during the week. How many hours of TV a day are you watching? Don't you think you could sub in one of those hours for exercise instead? That conversation has never worked in clinical practice to elicit change in my patients. Okay? When I hear my patients don't have time, that really tells me something more. It tells me a lot about their readiness to change their lifestyle. And this might be really the missing piece around some of our education surrounding physical activity. So after you ask your patients about their current activity levels and compare these to the traditional guidelines set out by the ACSM, those ACSM guidelines, you can start to assess their stage of change. I think that's the most important thing we answer first. How ready is my patient to change? How ready are they to change? So an important question could be, do you intend to change your physical activity in the next month or in the next six months? I'm trying to determine a timeline. Now you can decide based on the answer if they kind of fall into these different categories. Are they in the pre-contemplation phase? Meaning they're not interested in really changing their physical activity at all. Or are they in the contemplation phase? Do they intend to increase their physical activity in the next month or the next six months? And do they have a plan in place to make that change? Most of my patients really land in the pre-contemplative phase where they're not considering changing really anything. They're not coming to me for an exercise program. They just have a problem they want me to fix. Now if there's some, you might even meet somebody who's in a preparation phase, who's actually made a plan to change some of their physical activity. They've reached out to a local gym, something like that. And if they're in that preparation phase, you're going to want to follow up on what's their action plan to increase their physical activity levels. If someone is in the pre-contemplative stage of change, we want to validate their current perspective. We don't want to convince them to switch sides. Not yet. It's our turn to show them what physical activity can do in their lives and wait for them to be interested in doing more. This is a call to action to make sure our patients really see the value of rehab that we provide. They should see a super clear connection between their goals and the exercises we select. If our patients are in that contemplative phase without a plan, so they're thinking about it in the next six months, they don't really have a plan to get there, it's our job to develop specific goals for them and an action plan while assessing their confidence to committing the plan. I think that's what we miss is that confidence piece. We usually miss it and we only kind of set out a goal or action saying you're going to do this exercise five days a week, sounds good, I'll check back in on that later.

11:20 ASSESSING CONFIDENCE WITH EXERCISE

The confidence assessment is key. You can ask your patient how confident they feel on executing a plan. Ask them on a zero to 10 scale, how confident are you that you're going to be able to do this exercise program five days a week? If the patient says anything less than a seven out of 10, we need to reevaluate the goals and the action plan. We probably should drop that down. Do you think you're going to be able to get three days of exercise in a week? Assess confidence, super important. Now if the patient already has a plan going, it's worth it to stop and talk about barriers. The article mentions using the 27 item inventory of physical activity barriers, which works through a patient through eight domains of barriers that could impact physical activity. That is a super thorough assessment. 27 items is a lot. So this could be appropriate for some, maybe not for all. The simpler one would be the self-efficacy for exercise scale. That's a bit simpler. It's a far fewer items. I'm sorry, I don't remember the exact number, but it's far fewer items than 27. But if you're really interested in figuring out what's going to cause your patient to stop being physically active, these are assessments you definitely want to do. Now as your patient begins to execute their plan, it is our job to constantly check in. In the article they say, recognizing success is essential because it increases self-efficacy. And I couldn't agree more. I am all about and in the business of improving my patient's self-efficacy. Honestly, I wonder if that is the job of the physical therapist for the older adult at this point. Bringing our patients back in control of their lives and giving them this feeling and sensation of self-efficacy. So I'm a guide to that land of self-efficacy. Now how do we do that is we check in constantly with our patients about their program, their physical activity program. And we cheerlead and recognize and give kudos to every little step that our patient makes towards these goals and especially when they work around barriers to completing the activity. So make sure if you have physical activity goals for your patient that these are things you're asking about every session. We're not giving them the plan and then not checking back in. It's really our job to continue to check back in. It's why we are different than medical doctors who see our patients once every six months and you know six months to a year. At that six months to year visit our MDs are usually telling people, hey you have to be more active and that's all they're doing. No, we get to do the hard work and really check in with our patients how this plan is going.

14:00 AGE-FRIENDLY HEALTHCARE

Now this article also describes age-friendly healthcare which helps to foster a person-centered care. So for older adults in particular you kind of have to determine what matters. They call this the four M's but what matters, M matters, knowing what our patient's mentation state is which I love, taking this consideration towards dementia and delirium that we need to understand before giving these guidelines. Talking about mobility optimization that making sure our patients maintain high levels of mobility and safety is critically important to the population and optimizing medication. So there's a lot that goes inside of this, there's a lot that goes into this conversation rather of physical activity and addressing inadequate physical activity in older adults. This article was really lovely, I really recommend a look because in the back of the article there's a resource guide of all the different physical activity related measures that you can compare and contrast to see if you can find some that are appropriate for your patient population. It's at the very end of the article. So I'll link it in the Instagram page but just remember first and foremost we are in the business of addressing physical activity, absolutely. We have to recognize that we have a bias towards exercise that our patients do not have so we need to come back to that newbie state of mind and really address physical activity from that place and not from our high horse of exercise. By doing this we have to first assess my patient's readiness to change. How often are they thinking about implementing a physical activity program in their day to day life? Think about those things first before you start giving recommendations because if they're in the pre-contemplative phase of behavior change they are not ready to hear from us that they need to be doing a physical activity program. Not yet. Think about the barriers that our patients are going to encounter and potentially use some scales like the physical activity barrier scale or the self-efficacy for exercise scale to address these barriers that are going to inevitably pop up when we start engaging in a physical activity program. Think about some older adult specific techniques such as thinking about mentation, thinking about medication in order to optimize our recommendations. Alright, so you guys are in the business of increasing physical activity for older adults. It's actually probably one of the bigger parts of our job. 91% of older adults are not meeting physical activity guidelines so get out there, let's start attacking these numbers. Have a good Wednesday.

16:29 OUTRO

Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.