《老年健康与物理治疗》课程教学资源：《老年物理治》英文书籍教材（Geriatric Physical Therapy，Third Edition，Andrew A. Guccione、Rita A. Wong、Dale Avers）

CONTRIBUTORS .T,MS PT.PhD Cory Christiar Andre A Cu ione,PT,PhD University of Pittsburgh Physical Therapy Program ty Directo Physical Therapy Department Department of Physical Medicine Health Services Research Pittsburgh,Pennsylvania Sch Reh Development Service Dale Avers,PT,DPT,PhD Director Post Professional dpt Greg W.Hartley,PT,DPT,GCS Program CharD.Cicone,PT,PhD, Director of Rehabilitation Dep f Physical Therapy APTA Hospita College of Health Professions Department of Physical Therapy SUNY Upstate Medical University Ithaca College Director Syracuse,New York Ithaca.New York Katherine Beissner,PT,PhD Rhea Cohn PT DPT Hospitals Professor Health Care Consultant Miami, Department of Physical Therapy Washington,DC metro area Adiunct Assistant Professor Ithaca College Ithaca,New E.Edelstein,PT,MA,FISPO, ysical Therapy Diane Borello-France,PT,PhD Spe cial Lecturer Associate professor Program in Physical Therapy Columbia University New York,New York Associate Cathy S.Elrod.PT.PhD ical Thera Associate Professor Richard Briggs,MA,PT Department of Physical Therapy Grand Rapids,Michigan M spice and Catherine E.Lang PT,PhD Chico,California Christine E.Fordyce,PT,DPT Program in Physical Therapy Rehab Director Program in Occupational Marybeth Brown,PT,PhD,FAPTA Therapy ical Ther f Neurology Claire Gold,MSPT,MBA,COS-C, Saint Louis.Missouri University of Missour CPHQ Columbia,Missouri Home Health Age lhdniniuaor Tanya LaPier,PT,PhD,CCS Sabrina Camilo,PT,MSPT,GCS Private Practitione on University Sao Paulo.Brazil

Alia A. Alghwiri, PT, MS PhD candidate University of Pittsburgh Physical Therapy Department Pittsburgh, Pennsylvania Dale Avers, PT, DPT, PhD Associate Professor Director, Post Professional DPT Program Department of Physical Therapy Education College of Health Professions SUNY Upstate Medical University Syracuse, New York Katherine Beissner, PT, PhD Professor Department of Physical Therapy Ithaca College Ithaca, New York Diane Borello-France, PT, PhD Associate Professor Department of Physical Therapy Rangos School of Health Sciences Duquesne University Pittsburgh, Pennsylvania Richard Briggs, MA, PT Hospice Physical Therapist Enloe Medical Center, Hospice and HomeCare Chico, California Marybeth Brown, PT, PhD, FAPTA Professor Physical Therapy Program, Biomedical Sciences University of Missouri Columbia, Missouri Sabrina Camilo, PT, MSPT, GCS Private Practitioner São Paulo, Brazil C O N T R I B U T O R S Cory Christiansen, PT, PhD Assistant Professor Physical Therapy Program Department of Physical Medicine & Rehabilitation School of Medicine University of Colorado Aurora, Colorado Charles D. Ciccone, PT, PhD, FAPTA Professor Department of Physical Therapy Ithaca College Ithaca, New York Rhea Cohn, PT, DPT Health Care Consultant Washington, DC metro area Joan E. Edelstein, PT, MA, FISPO, CPed Special Lecturer Program in Physical Therapy Columbia University New York, New York Cathy S. Elrod, PT, PhD Associate Professor Department of Physical Therapy Marymount University Arlington, Virginia Christine E. Fordyce, PT, DPT Rehab Director Gentiva Health Services Auburn, New York Claire Gold, MSPT, MBA, COS-C, CPHQ Home Health Agency Administrator Gentiva® Home Health San Diego, California Andrew A. Guccione, PT, PhD, DPT, FAPTA Deputy Director Health Services Research & Development Service Department of Veterans Affairs Washington, DC Greg W. Hartley, PT, DPT, GCS Director of Rehabilitation & Assistant Hospital Administrator, Geriatric Residency Program Director St. Catherine’s Rehabilitation Hospitals and Villa Maria Nursing Centers Miami, Florida; Adjunct Assistant Professor University of Miami Miller School of Medicine Department of Physical Therapy Coral Gables, Florida Barbara J. Hoogenboom, PT, EdD, SCS, ATC Associate Professor Program in Physical Therapy Grand Valley State University Grand Rapids, Michigan Catherine E. Lang PT, PhD Assistant Professor Program in Physical Therapy Program in Occupational Therapy Department of Neurology Washington University Saint Louis, Missouri Tanya LaPier, PT, PhD, CCS Professor Eastern Washington University Cheney, Washington vii

vi CONTRIBUTORS nOIAnTMH,wD ycal Therapy Dep ant Profe Salt lake city.utah Rehabilitation Scien and Rehabilitation Sciences- Carleen Lindsey,PT,MScAH,GCs argen Boston,Massachusetts College Park,Maryland Backs Balance Bristol.Connecticut John Rabbia,PT,DPT,MS,GCS, Karin Westlen-Boyer,DPT,MPH Toby M.L 匹PhD,FAPTA CWS Intermountain Health Fitness ation of Hospital Pediatrics City,U Director of Training Barbara Resnick,PhD,CRNP, Mary Ann Wharton,PT,MS Center for Child and Human AAN,FAANP Associate Professor and Prof Curriculum Co igo.DC orkin Gershowitz Chair in ie I Therapy University of Maryland School of Michelle M.Lusardi,PT,DPT,PhD Adjunct Associate Professor Physical Therapist Assistant College of Education and Health Julie D.Ries,PT,PhD Associate Professor College of Allegheny County,Boyce Campus Professions Program in Physical Therapy Monroeville,Pennsylvania Marymount University Arlington,Virginia .AT PT,DPT,PhD Robin L.Marcus,PT,PhD,OCS Kathleen Toscano.MHS.PT.PCS Associate professor Assistant Professor Program in Physical Therapy and Olne rgh Carol A.Miller,PT,PhD,GCS Patrick J.VanBeveren,PT,DPT, Ann K.Williams,PT,PhD MA,O e Program in Physica Health erapy Services ege of H Professions and North Ge orgia college state on Center The University of Montana University Syracuse,New York Missoula.Montana Dahlonega,Georgia ART ment and Profe Payment Advocac School of Physical Therapy Professor of Physical Therapy American Physical Th erapy dr(A Martha Walker.PT.DPT Karen Mueller,PT,PhD Clinical Instructor Professor Physical Therapy and Rehabilitation of marvland Department of Physical Therapy Baltimore.Maryland Northern Arizona University Flagstaff.Arizona

viii CONTRIBUTORS Paul LaStayo, PT, PhD, CHT Associate Professor Department of Physical Therapy University of Utah Salt Lake City, Utah Carleen Lindsey, PT, MScAH, GCS Physical Therapist Bones, Backs & Balance Bristol, Connecticut Toby M. Long, PT, PhD, FAPTA Associate Professor Department of Pediatrics Director of Training Center for Child and Human Development Georgetown University Washington, DC Michelle M. Lusardi, PT, DPT, PhD Professor Emerita Department of Physical Therapy and Human Movement Science College of Education and Health Professions Sacred Heart University Fairfield, Connecticut Robin L. Marcus, PT, PhD, OCS Assistant Professor Department of Physical Therapy University of Utah Salt Lake City, Utah Carol A. Miller, PT, PhD, GCS Professor Doctorate Program in Physical Therapy North Georgia College & State University Dahlonega, Georgia Justin Moore, PT, DPT Vice President, Government and Payment Advocacy American Physical Therapy Association (APTA) Alexandria, Virginia Karen Mueller, PT, PhD Professor College of Health and Human Services Department of Physical Therapy Northern Arizona University Flagstaff, Arizona Jean Oulund Peteet, PT, MPH, PhD Clinical Assistant Professor Department of Physical Therapy and Athletic Training Boston University College of Health and Rehabilitation Sciences– Sargent Boston, Massachusetts John Rabbia, PT, DPT, MS, GCS, CWS Visiting Nurse Association of Central New York Barbara Resnick, PhD, CRNP, FAAN, FAANP Professor Sonya Ziporkin Gershowitz Chair in Gerontology University of Maryland School of Nursing College Park, Maryland Julie D. Ries, PT, PhD Associate Professor Program in Physical Therapy Marymount University Arlington, Virginia Kathleen Toscano, MHS, PT, PCS Pediatric Physical Therapist Montgomery County Infant and Toddler Program Olney, Maryland Patrick J. VanBeveren, PT, DPT, MA, OCS, GCS, CSCS Director of Physical Therapy Services St. Camillus Health and Rehabilitation Center Syracuse, New York Michael Voight, PT, SCS, OCS, ATC, CSCS Professor School of Physical Therapy Belmont University Nashville, Tennessee Martha Walker, PT, DPT Clinical Instructor Physical Therapy and Rehabilitation Science University of Maryland Baltimore, Maryland Chris L. Wells, PhD, PT, CCS, ATC Assistant Professor–Part Time, Department of Physical Therapy & Rehabilitation Science University of Maryland School of Medicine College Park, Maryland Karin Westlen-Boyer, DPT, MPH Intermountain Health & Fitness Institute at LDS Hospital Salt Lake City, Utah Mary Ann Wharton, PT, MS Associate Professor and Curriculum Coordinator Department of Physical Therapy Saint Francis University Loretto, Pennsylvania; Adjunct Associate Professor Physical Therapist Assistant Program Community College of Allegheny County, Boyce Campus Monroeville, Pennsylvania Susan L. Whitney, PT, DPT, PhD, NCS, ATC, FAPTA Associate Professor Program in Physical Therapy and Otolaryngology University of Pittsburgh Pittsburgh, Pennsylvania Ann K. Williams, PT, PhD Adjunct Professor College of Health Professions and Biomedical Sciences The University of Montana Missoula, Montana Rita A. Wong, EdD, PT Physical Therapy Department Chairperson Professor of Physical Therapy Marymount University Arlington, Virginia

PREFACE e of this textbook has not changed since the first provide nuance to examination findings or modulate the edition 18 years ago.The editors'intent for undertaking outcomes of intervention.Part IlI provides the scientific andaicnrpPrableeate em ematic o tools to integrate health and functional status informa comes.In the tion with examination data,formulate an accurate diag. next section,the chapters cover some health conditions nosis,and that care settings adults but represent points of of phy informed advocate for older adults.What has changed Thehercapis in rppic ication of rha the original pubication for ened t in Part Finally, section g for the exar ce that can pel or obstruct the ofession's abil to be certified as geriatric clinical specialist as well as ityothe efradph health of the nation:reimbursement and advocacy. mos t gratifyin Geriatri What started as an attempt to update a w nd t ceive th of c ertified the cha atric physical therapyand the area all attest to the fact that physical therapist practice 20 vears The goals which we first described in 1993 and oriented toward ol dults is no onger a ne velty,con epeated the secon edition remain:to denne the sc sis population.On the contrar.griatris physical physical therapist practice in general;and to promote the ion in practice and cuing adoption of evidence-based principles of clinical care e physical therapists to exer hat advanc geriatric physical therapist practice.It is oug from primary prevention to end-of-life care. that we have contributed to this phenomenon. The new edition of Geriatric Physical Therapy has organize cphys Andrew A.Guccione,ThD.DT vers,PT,DPT.PhD ology of disease and disability.Next,our contributors

P R E F A C E Although the content of previous editions has been sub￾stantially revised, it is remarkable that the overall pur￾pose of this textbook has not changed since the first edition 18 years ago. The editors’ intent for undertaking the third edition of Geriatric Physical Therapy is to as￾sist the development of reflective physical therapists who can use the available scientific evidence and objective tools to integrate health and functional status informa￾tion with examination data, formulate an accurate diag￾nosis, and design effective treatment plans that can be implemented at all levels of care and across all settings to produce optimal outcomes. We further believe that this practitioner can serve both patients and society as an informed advocate for older adults. What has changed throughout the years is that the original publication was intended only as a textbook for entry-level students. In the intervening years we have expanded the vision of this text to include individuals studying for the examination to be certified as geriatric clinical specialist as well as practicing clinicians. The last group is perhaps the most surprising and the most gratifying. Geriatric physical therapy has come into its own in the last two decades. The emergence of the specialty, the growth of certified specialists, and the number of practicing clinicians in the area all attest to the fact that physical therapist practice oriented toward older adults is no longer a novelty, con￾fined to a few physical therapists whose good hearts and intentions led them to concerns about America’s aging population. On the contrary, geriatric physical therapy is bursting with innovation in practice and cutting edge research that will enable physical therapists to exercise the full range of their education, experience, and exper￾tise across the full continuum of the health care system from primary prevention to end-of-life care. The new edition of Geriatric Physical Therapy has been arranged in six parts. In Part I, we organize the foundational sciences of geriatric physical therapy, which range from basic physiology of aging to clinical epidemi￾ology of disease and disability. Next, our contributors explore the personal and environmental contexts of ex￾amination and intervention, particularly as these factors provide nuance to examination findings or modulate the outcomes of intervention. Part III provides the scientific basis for evaluation and diagnosis of prototypical health conditions and patient problems that are emblematic of geriatric physical therapy as well as the design of plans of care for effective treatment and optimal outcomes. In the next section, the chapters cover some health conditions that are not common to the entire population of older adults but represent points of substantial health impact requiring specific expertise to be addressed effectively. The practice of physical therapists in our application of specific education, experience, and expertise in the health problems of older adults across spectrum of healthcare delivery is presented in Part V. Finally, the last section tackles the societal issues affecting physical therapist practice that can propel or obstruct the profession’s abil￾ity to address the health of older adults and optimize the health of the nation: reimbursement and advocacy. What started as an attempt to update a well-received resource was infused with a new vision and turned into a substantial revision to reflect the changes in geri￾atric physical therapy and the profession itself in the last 20 years. The goals which we first described in 1993 and repeated in the second edition remain: to define the sci￾entific basis of physical therapy; to describe how physi￾cal therapist practice with older adults differs from physical therapist practice in general; and to promote the adoption of evidence-based principles of clinical care that advance geriatric physical therapist practice. It is clear now that the best scientific thoughts are being translated into clinical actions. We are pleased to think that we have contributed to this phenomenon. Andrew A. Guccione, PT, PhD, DPT, FAPTA Rita A. Wong, EdD, PT Dale Avers, PT, DPT, PhD ix

ACKNOWLEDGMENTS This is truly a textbook that reunites an old team with to find each other then;we know now we were blessed some long-t rm colleagues, ces a sub with an exciting intellectual partnership and profes. stantial nu of new ted to christie Hart for encouragin to undertake a third edition.While the response to the of geriatric physical therapist practice had of collab he team at orative practice in g geriatric physical therapy.As it hap Ultimately,we recognize that whatever we might out geriatric physical therapy is the summation is,a prot the tists,clinicians Du EEA品 aryb Andrew A.Guccione,T DT uted he expert the

x CHAPTER 12 Chapter Title Goes Here x A C K N O W L E D G M E N T S This is truly a textbook that reunites an old team with some long-term colleagues, but also introduces a sub￾stantial number of new contributors that allows us to appreciate the vitality of geriatric physical therapy and the profession itself. Their vibrant contributions, joined with cutting-edge expertise, have expanded the horizons of this text and enriched us as professionals committed to practice with older adults. The editorial team exemplifies the essence of collab￾orative practice in geriatric physical therapy. As it hap￾pens, we had worked together before on what was, and still is, a professional career highlight for all of us: the development of the geriatric specialty examination. Dur￾ing that venture, our special contributor and friend, Marybeth Brown, was a full member of the team. For this venture, our “silent” partner in developing the ex￾amination, Dale Avers, switched places with Marybeth, taking the on-stage role while Marybeth contributed her singular expertise from the wings. It seemed fortuitous to find each other then; we know now we were blessed with an exciting intellectual partnership and profes￾sional friendship. We are indebted to Christie Hart for encouraging us to undertake a third edition. While the response to the previous editions was very positive, we knew the scope of geriatric physical therapist practice had evolved sub￾stantially necessitating a global revision. The team at Mosby/Elsevier has supported us each step of the way. Ultimately, we recognize that whatever we might know about geriatric physical therapy is the summation of countless interactions with scientists, clinicians, edu￾cators and students, but most of all our patients. It is in recognition of their primary role in teaching us as well as our families in supporting us that this work is dedicated. Andrew A. Guccione, PT, PhD, DPT, FAPTA Rita A. Wong, EdD, PT Dale Avers, PT, DPT, PhD

PA RT Foundations

1 P A R T Foundations I

CHAPTER 1 Geriatric Physical Therapy in the 21st Century: Overarching Principles and Approaches to Practice Rita A.Wong,EdD,PT INTRODUCTION and a of p THERAPY working in settings traditionally identified as "geriat- Evidence-Based Practice ledge ahorectotfoiecrndbfd& dvidence-based practice is an approacd patient at least40%of patients across physical therapy clinical settings.Although the fundamental principles of about the care of a patient.Figure 1-1 illustrates these patient management are similar regardless of patient age,there are ons in the mprove practice ometm This chapter starts with a brief discussion of the misleads people into thinking that the scientific evidence is the only factor to be considered when using hegrpnded practice:optima this approach a patient-care de geriabctivity in the use of ouy the role o rcise and physical makingoy one of the three ctal com nt of edible clinical decision ofac chapter con a h is evic rmed practice. mechanisms required o enare aded nding role:it then moves pret and apply this literature in the context of an in the ave expertise to yperform the ap. pret the findings in light of age-related and condition- adults. specific characteristics of the patient,and then to skillfully Copyright2012,2000,1993 by Mosby,Inc.an affiliate of Elsevier Inc

2 Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. C H A P T E R 1 Geriatric Physical Therapy in the 21st Century: Overarching Principles and Approaches to Practice Rita A. Wong, EdD, PT INTRODUCTION This book promotes the reflective, critical, objective, and analytical practice of physical therapy applied to the older adult. All physical therapists, not just those working in settings traditionally identified as “geriat￾ric,” should possess strong foundational knowledge about geriatrics and be able to apply this knowledge to a variety of older adults. Indeed, older adults comprise at least 40% of patients across physical therapy clinical settings.1 Although the fundamental principles of patient management are similar regardless of patient age, there are unique features and considerations in the management of older adults that can greatly improve outcomes. This chapter starts with a brief discussion of the key principles and philosophies upon which the book is grounded: evidence-based practice; optimal aging; the slippery slope of aging; clinical decision making in geriatrics; the role of exercise and physical activity for optimal aging; objectivity in the use of outcome assessment tools; and the importance of patient values and motivation. The chapter continues with a discus￾sion of the geriatric practitioner of the future and mechanisms required to prepare adequate numbers of practitioners for this expanding role; it then moves to the key principles of locating, analyzing, and applying best evidence in the care of older adults. The chapter ends with a discussion of ageism and the impact of ageism on health care services to older adults. KEY PRINCIPLES UNDERLYING CONTEMPORARY GERIATRIC PHYSICAL THERAPY Evidence-Based Practice Evidence-based practice is an approach to clinical decision making about the care of an individual patient that integrates three separate but equally important sources of information in making a clinical decision about the care of a patient. Figure 1-1 illustrates these three information sources: (1) best available scientific evidence, (2) clinical experience and judgment of the practitioner, and (3) patient preferences and moti￾vations.2 The term evidence-based practice sometimes misleads people into thinking that the scientific evidence is the only factor to be considered when using this approach to inform a patient-care decision. Although the scientific literature is an essential and substantive component of credible clinical decision making, it is only one of the three essential compo￾nents.2,3 An alternative, and perhaps more accurate, label for this approach is evidence-informed practice. The competent geriatric practitioner must have a good grasp of the current scientific literature and be able to interpret and apply this literature in the context of an individual patient situation. This practitioner must also have the clinical expertise to skillfully perform the ap￾propriate tests and measures needed for diagnosis, inter￾pret the findings in light of age-related and condition￾specific characteristics of the patient, and then to skillfully

CHAPTER 1 Geriatric Physical Therapy in the 21st Century Best mel-Smiths anded the oncept of Rowe inclusive term than aging.Brummel-Smith defines optimal aging as "the capacity to function across many domains Patien and on tualization recognizes the impe rtance of timizi functional capacity in older adults regardless of the epenSd presence or absence of a chronic FIGURE 1-1 Key elements of evidence-informed practice. vith ch hea sing lev of disability lea ditioning that further decreases functional ability.Thes communica- declines lead to secondary conditions assoc d wit ns ar to ac new dis tal in reducing the disabling effects of chronic disease processes by promoting restorative and accommodative Optimal Aging changes that stop or reverse the downwar n owing the Rowe and Kahn+first intr aging and usual the pres remind practitioners and researchers that the typical olde Slippery Slope of Aging aging)are quite var mal a style g-re of a of opt as physical activity,nutrition,and stress management resents encourages practitioners to consider er adu sa substantial propor d as that observe wit Th along the v-axis regardless of age can be modified Ten years later,Rowe and Kahns provided further (in either a positive or negative direction)based on s of aging 100 90 80 Fun ability to readily en 50 Function avoid 2 health care practitioners,the reality is that the majorit 10 of older adults do have at least one chronic health condi Failure 100+ Age ctondl associate wit For this large group of individuals.Rowe and Kahn's FIGURE 1-pperspfn depicts model needs to stretch beyond the concept of avoidance of disease and disability

CHAPTER 1 Geriatric Physical Therapy in the 21st Century 3 apply the appropriate interventions to best manage the problem. This is all done with clear and full communica￾tion with the patient to assure the goals and preferences of the patient are a central component of the develop￾ment of a plan of care. Optimal Aging Rowe and Kahn4 first introduced the terms successful and usual aging in the mid-1980s as a mechanism to remind practitioners and researchers that the typical changes in physiological functioning observed in older adults (usual aging) are quite variable and generally represent a combination of unavoidable aging-related changes and modifiable (avoidable) lifestyle factors such as physical activity, nutrition, and stress management. Their perspective encourages practitioners to consider that for many older adults, a substantial proportion of apparent age-related changes in functional ability may be partially reversible with lifestyle modification programs. Ten years later, Rowe and Kahn5 provided further clarification of the key components that make up their model for successful aging. The specific elements they present as the signs of an individual who is aging success￾fully are (1) absence of disease and disability, (2) high cognitive and physical functioning, and (3) active engage￾ment with life. Rowe and Kahn describe a usual aging syndrome as one in which suboptimal lifestyle leads to chronic health problems that affect function and thus the ability to readily engage in family or community activi￾ties. Improving healthy lifestyle is encouraged as a means of achieving successful aging. Although helping older adults avoid disease and disease-related disability is a central consideration for all health care practitioners, the reality is that the majority of older adults do have at least one chronic health condi￾tion and many, particularly among the very old, live with functional limitations and disabilities associated with the sequela of one or more chronic health conditions. For this large group of individuals, Rowe and Kahn’s model needs to stretch beyond the concept of avoidance of disease and disability. Brummel-Smith6 expanded the concepts of Rowe and Kahn in the depiction of optimal aging as a more inclusive term than successful aging. Brummel-Smith defines optimal aging as “the capacity to function across many domains—physical, functional, cognitive, emotional, social, and spiritual—to one’s satisfaction and in spite of one’s medical conditions.”6 This concep￾tualization recognizes the importance of optimizing functional capacity in older adults regardless of the presence or absence of a chronic health condition. Functional limitations associated with chronic health conditions often lead to a vicious downward cycle with increasing levels of disability leading to greater decon￾ditioning that further decreases functional ability. These declines lead to secondary conditions associated with chronic conditions and, often, to additional new dis￾eases. Physical therapists can be particularly instrumen￾tal in reducing the disabling effects of chronic disease processes by promoting restorative and accommodative changes that stop or reverse the vicious downward functional cycle, allowing the individual to achieve optimal aging in the presence of chronic health condi￾tions. Slippery Slope of Aging Closely linked to the concept of optimal aging is the concept of a “slippery slope” of aging (Figure 1-2). The slope, originally proposed by Schwartz,7 represents the general decline in overall physiological ability (that Schwartz expressed as “vigor”) that is observed with increasing age. The curve is arbitrarily plotted by decade on the x-axis so the actual location of any individual along the y-axis—regardless of age—can be modified (in either a positive or negative direction) based on Patient Best available evidence Clinical expertise/judgment Patient preferences and motivations FIGURE 1-1 Key elements of evidence-informed practice. 100 90 80 70 60 50 40 30 20 10 20 100 Vigor (percent) Age Fun Function Frailty Failure FIGURE 1-2 Slippery slope of aging depicts the general decline in overall physiological ability observed with increasing age and its impact on function. (Adapted from Schwartz RS: Sarcopenia and physical performance in old age: introduction. Muscle Nerve Suppl5: S10-S12, 1997.)

4 CHAPTER 1 Geriatric Physical Therapy in the 21st Century lifestyle factors and illness that influence physiological funioning ation that must be brought to bear on a inica er amew s are pre this ally the into model is grounded in the patient-client management can have a large imp model the Guide to Physica Therapist Practice part an em zes th al ro fra erapy nt disablement concept of the World Health Organiza in work, home. leisure activities nationa nto function continues ICF)m ty'are als and of di restrict leisure activities (fun)because of declining physi- substantial emphasis on describing and explaining per- ological capacity.Mov medic environmenta fact rs likely to en- managing Crucial Role of Physical Activity and Exercise in Maximizing Optimal Aging into wo whe ndiv nde concern across age groups th BADl The concept of functional thresholds and the down- ward mo fun to exercise sustainabil o regain physi ical reser appareof rved between t hat physi menrs)and chan ofcare for their older adult patients r as par for a person who is teetering between the thresholds of Exercise may well be the most important tool on and f physical erapist has to positively affect function and “frailt aging.De with its associated functional limitations.Once a per optimal intensity. duration and mode of exercise r moves to a lower functional level (down the curve of the scription,physical therapists often underutilize exercise. optimal negative on the potent to up to a high of tim cise activities may enhance efforts for an up ions may be ciated with such fa ment along the slippery slope.Moreove the furth that lower expe ctations for high levels of function.ack reshold. th of awareness of age-based functional norms hat can b more physi ava P A goa ure ot d h d pe ve role of phy cal the r the of in prevention)that are covered and reimbursed tients/c to und person's insurance benefit.Physica t physiological reserve should every opport nity to apply evi Clinical Decision Making in Geriatric ams that encourage p ositive lifestyle changes and, Physical Therapy thus.maximize optimal aging. eof physical therapy practice sth Objectivity in Use of Outcome Tools ovement and health.Providing a fram rk for clini Older adults be me increasingly dissimilar with increa cal decision making in geriatric physical therapy 1 ing age.A similarly aged person can be frail and reside in particularly important because of the sheer volume of a nursing home or be a senior athlete participating in a

4 CHAPTER 1 Geriatric Physical Therapy in the 21st Century lifestyle factors and illness that influence physiological functioning. Schwartz has embedded functional status thresholds at various points along this slope. Conceptually, these thresholds represent key impact points where small changes in physiological ability can have a large impact on function, participation, and disability. These four distinctive functional levels are descriptively labeled fun, function, frailty, and failure. Fun, the highest level, repre￾sents a physiological state that allows unrestricted par￾ticipation in work, home, and leisure activities. The person who crosses the threshold into function continues to accomplish most work and home activities but may need to modify performance and will substantially self￾restrict leisure activities (fun) because of declining physi￾ological capacity. Moving from function into frailty oc￾curs when managing basic activities of daily living (BADLs; walking, bathing, toileting, eating, etc.) con￾sumes a substantial portion of physiological capacity, with substantial limitations in ability to participate in community activities and requiring outside assistance to accomplish many home or work activities. The final threshold into failure is reached when an individual re￾quires assistance with BADLs as well as instrumental daily activities and may be completely bedridden. The concept of functional thresholds and the down￾ward movement from fun to frailty helps explain the apparent disconnect that is often observed between the extent of change of physiological functions (impair￾ments) and changes in functional status. For example, for a person who is teetering between the thresholds of function and frailty, a relatively small physiological chal￾lenge (a bout of influenza or a short hospitalization) is likely to drop them squarely into the level of “frailty,” with its associated functional limitations. Once a person moves to a lower functional level (down the curve of the y-axis) it requires substantial effort to build physiologi￾cal capacity to move back up to a higher level (back up the y-axis). Lifestyle changes including increased exer￾cise activities may enhance efforts for an upward move￾ment along the slippery slope. Moreover, the further the person is able to move above a key threshold, the more physiological reserve is available for protection from an acute decline in a physiological system. A major role of physical therapy is to maximize the movement￾related physiological ability (vigor) of older adult pa￾tients/clients to keep them at their optimal functional level and with highest physiological reserve. Clinical Decision Making in Geriatric Physical Therapy The primary purpose of physical therapy practice is the enhancement of human performance as it pertains to movement and health. Providing a framework for clini￾cal decision making in geriatric physical therapy is particularly important because of the sheer volume of information that must be brought to bear on a clinical decision. Several conceptual frameworks are presented in Chapter 6 and integrated into a model to guide phys￾ical therapy clinical decision making in geriatrics. The model is grounded in the patient-client management model of the Guide to Physical Therapist Practice8 and emphasizes the central role of functional movement task analysis in establishing a physical therapy diagnosis and guiding choice of interventions. The enablement– disablement concepts of the World Health Organiza￾tion’s International Classification of Functioning, Dis￾ability and Health (ICF) model of disability9 are also incorporated into this model, using ICF language to communicate the process of disablement and placing a substantial emphasis on describing and explaining per￾sonal, medical, and environmental factors likely to en￾able functional ability or increase disability. Crucial Role of Physical Activity and Exercise in Maximizing Optimal Aging Lack of physical activity (sedentary lifestyle) is a major public health concern across age groups. Only 22% of older adults report engaging in regular leisure-time physical activity.10 Sedentary lifestyle increases the rate of age-related functional decline and reduces capacity for exercise sustainability to regain physiological reserve following an injury or illness. It is critical that physical therapists overtly address sedentary behavior as part of the plan of care for their older adult patients. Exercise may well be the most important tool a physical therapist has to positively affect function and increase physical activity toward optimal aging. Despite a well-defined body of evidence to guide decisions about optimal intensity, duration, and mode of exercise pre￾scription, physical therapists often underutilize exercise, with a negative impact on the potential to achieve optimal outcomes in the least amount of time. Underuti￾lization of appropriately constructed exercise prescrip￾tions may be associated with such factors as age biases that lower expectations for high levels of function, lack of awareness of age-based functional norms that can be used to set goals and measure outcomes, and perceived as well as real restrictions imposed by third-party payers regarding number of visits or the types of interventions (e.g., prevention) that are covered and reimbursed under a person’s insurance benefit. Physical therapists should take every opportunity to apply evidence-based recommendations for physical activity and exercise programs that encourage positive lifestyle changes and, thus, maximize optimal aging. Objectivity in Use of Outcome Tools Older adults become increasingly dissimilar with increas￾ing age. A similarly aged person can be frail and reside in a nursing home or be a senior athlete participating in a

CHAPTER 1 Geriatric Physical Therapy in the 21st Century Physical therapists who find geriatrics particularly rewarding and exciting tend to be practitioners who dislike a clinical world of "routine ,and patients with n es,can provide a more c ers enjoy ng creative mance relative to similarly aged oder adu servings highest level of optimal aging and enjoy making common language and as a baseline for measuring prog personal impact on the care of their patients.Navigating tminute wall eent an effective solution in the mids test (175 m). en 01 rovides a more ate des tion than“an older ma who requires mod assistance of two to transfer,walks a walker,and whose strength is WFL. Need for Physical Therapists in Geriatrics tests,appropriate The year 2011 marks a critical date for the Americar he of the baby-boomer generation ued 65 years.This group,born post-World War II,is mucl RED on,both in terms of ON numb er c ing this era( f th 946o1965j Physical therapists working with older adults must ingly although health services rchers have lon be prepared to serve as autonomous primary care casted the substantial impact of this demographi re searchers utors adequate prepar ion has bee tes,in to m et the Although none of these roles is unique to geriatric group of older adults.The 2008 landmark report of ical erapy,what is unique is the remarkable s and the regularity provides physic le ide all le health care workforce (professional,technical,unskilled direct care worker,and family caregiver).These short- them to n L short physica the the apy status and may be simultaneously dealing with signifi- health care practitioners and the depth of preparation cant psychosocial stresses such as loss of a spouse,loss of these practitioners.The goal of this textbook is to of an important aspect of indepen or a change in tosupport physical thera- us,cogr epressio d size ble eload of physical aspects and provide an additive challenge to the physical therapy practices is the older adult. physical therapist.The physical therapist must be cre- clues about un the c r acc 88 ated acros s,are pa epresents mutually ed-ongoa ptions,the majority of the caseload of the aver physical therapist will soon consist of older adults making the Despite this,physical therapists still tend to think about therapist ethe tha geriatrics only as care pr in a nur sing home or geriatric physical ther- apy,physical therapists must recognize and be ready to vide effective services for the high volume of older ed cation to patient adult patients across all practice settings.Every physica

CHAPTER 1 Geriatric Physical Therapy in the 21st Century 5 triathlon. Dissimilarities cannot be attributed to age alone and can challenge the therapist to set appropriate goals and expectations. Functional markers are useful to avoid inappropriate stereotyping and undershooting of an older adult’s functional potential. Functional tests, especially those with normative values, can provide a more objective and universally understood description of actual perfor￾mance relative to similarly aged older adults, serving as a common language and as a baseline for measuring prog￾ress. For example, describing an 82-year-old gentleman in terms of gait speed (0.65 m/s), 6-minute walk test (175 m), Berg balance test (26/56), and Timed 5-repetition chair rise (0) provides a more accurate description than “an older man who requires mod assistance of two to transfer, walks 75 feet with a walker, and whose strength is WFL.” Reli￾able, valid, and responsive tests, appropriate for a wide range of abilities, enhance practice and provide valuable information for our patients and referral sources. THE PATIENT-CENTERED PHYSICAL THERAPIST ON THE GERIATRIC TEAM Physical therapists working with older adults must be prepared to serve as autonomous primary care practitioners, and as consultants, educators (patient and community), clinical researchers (contributors and critical assessors), case managers, patient advocates, in￾terdisciplinary team members, and practice managers.11 Although none of these roles is unique to geriatric phys￾ical therapy, what is unique is the remarkable variability among older adult patients and the regularity with which the geriatric physical therapist encounters patients with particularly complex needs. Unlike the typical younger individual, older adults are likely to have several complicating comorbid conditions in addition to the condition that has brought them to physical therapy. Patients with similar medical diagnoses often demonstrate great variability in baseline functional status and may be simultaneously dealing with signifi￾cant psychosocial stresses such as loss of a spouse, loss of an important aspect of independence, or a change in residence. Thus, cognitive issues such as depression, fear, reaction to change, and family issues can compound the physical aspects and provide an additive challenge to the physical therapist. The physical therapist must be cre￾ative, pay close attention to functional clues about un￾derlying modifiable or accommodative impairments, and listen carefully to the patient to assure goal setting truly represents mutually agreed-upon goals. In addition, the older patient is likely to be followed by multiple health care providers, thus making the physical therapist a member of a team (whether that team is informally or formally identified). As such, the physical therapist must share information and consult with other team members; recognize signs and symp￾toms that suggest a need to refer out to other practitio￾ners; coordinate services; provide education to patient and caretaker/family; and advocate for the needs of patients and their families. Physical therapists who find geriatrics particularly rewarding and exciting tend to be practitioners who dislike a clinical world of “routine” patients. These prac￾titioners enjoy being creative and being challenged to guide patients through a complex maze to achieve their highest level of optimal aging; and enjoy making a more personal impact on the care of their patients. Navigating an effective solution in the midst of a complex set of patient issues is professionally affirming and rarely dull or routine. Need for Physical Therapists in Geriatrics The year 2011 marks a critical date for the American population age structure, representing the date when the first wave of the baby-boomer generation turned age 65 years. This group, born post–World War II, is much larger than its preceding generation, both in terms of number of children born during this era (1946 to 1965) and increased longevity of those in that cohort. Interest￾ingly, although health services researchers have long forecasted the substantial impact of this demographic shift on the health care system and encouraged coordi￾nated planning efforts, inadequate preparation has been made to assure sufficient numbers of well-prepared health care practitioners to meet the needs of this large group of older adults. The 2008 landmark report of the Institute of Medicine (IOM) Retooling for an Aging America12 provides a compelling argument for wide￾ranging shortages of both formal and informal health care providers for older adults across all levels of the health care workforce (professional, technical, unskilled direct care worker, and family caregiver). These short￾ages include shortages of physical therapists and physical therapist assistants. The report provides numer￾ous recommendations for enhancing the number of health care practitioners and the depth of preparation of these practitioners. The goal of this textbook is to provide a strong foundation to support physical thera￾pists who work with older adults. A sizeable proportion of the caseload of most physical therapy practices is the older adult. A recent large-scale physical therapist practice analysis1 reported that 40% to 43% of the caseload of physical therapists, aggregated across clinical practice settings, are patients age 66 years or older. Undoubtedly, with very few ex￾ceptions, the majority of the caseload of the average physical therapist will soon consist of older adults. Despite this, physical therapists still tend to think about geriatrics only as care provided in a nursing home or, perhaps, in home care. Although these are major and important practice settings for geriatric physical ther￾apy, physical therapists must recognize and be ready to provide effective services for the high volume of older adult patients across all practice settings. Every physical

6 CHAPTER 1 Geriatric Physical Therapy in the 21st Century atricpist should be well grounded n ooidrakin s recommen ions related to were Clinical Expertise in Physical Therapy lifelong learning.Experts sought out mentors and could Clinical 15 of the three ancho EB er for enhanc sion m alt practice and used self-reflection regularly to identif movwdge chnical reasoning,vei strengths and weaknesses in their knowledge or though ou proce thei ongoing se nprovement :1-3.hment from ner(physical therapy student)typically examines each about what he or she could have done differently that dimension as a disc rete entity.As professional develop- ul have allowed the pa ment progresses,the egins to see th Exper actce The apy.The ps a an h ops.Expert practitioners describe these four dimensions ssed from novice to expert.Figure 1-4 illustrates as closely interwoven concepts and explain their rela tionships in terms o vell-articula ophy expre dcs generalis f a decision making with the patient. erts started their careers anticipating specialization in This model for expert-practice professional develop- ment was examined for each of four physical therapy ence as a nev ndradni Clinical Expertise they had for workine with older adults and were called to action by their perceptions that many at-risk older adults were receiving inadequate care.They became Virtue Life sp ach 04 Students Education Novice nal attribute Hunger for knowledo irtue Do the right thing Energy em Phi sophy of practic Competen Maste Teaching Professional development FIGURE 1-3 De FIGURE 1-4 Conceptual model rating the factors From GM G Hack LN rd KF.Expertise in

6 CHAPTER 1 Geriatric Physical Therapy in the 21st Century therapist should be well grounded in the science of geri￾atrics and gerontology in order to be effective in making evidence-based clinical decisions related to older adults. Clinical Expertise in Physical Therapy Clinical expertise is one of the three anchors to EBP. Jensen and colleagues,13 through a series of well-planned qualitative studies using grounded theory methodology, identified four core dimensions of expert physical thera￾pist practice: knowledge, clinical reasoning, virtue, and movement. These four dimensions provide a theoretical model to examine professional development from novice to expert. As depicted in Figure 1-3, the novice practitio￾ner (physical therapy student) typically examines each dimension as a discrete entity. As professional develop￾ment progresses, the practitioner begins to see the inter￾relationships among the dimensions, with recognition of overlap becoming obvious as clinical competence devel￾ops. Expert practitioners describe these four dimensions as closely interwoven concepts and explain their rela￾tionships in terms of a well-articulated philosophy of practice. The core of the expert physical therapist’s philosophy of practice is patient-centered care that values collaborative decision making with the patient. This model for expert-practice professional develop￾ment was examined for each of four physical therapy specialty areas (orthopedics, neurology, pediatrics, geriat￾rics) using board-certified clinical specialists recommended by peers as expert clinicians. All specialists were found to be highly motivated, with a strong commitment to lifelong learning. Experts sought out mentors and could clearly describe the role each mentor had in their develop￾ment, whether for enhanced decision making, professional responsibilities, personal values, or technical skill devel￾opment. Experts had a deep knowledge of their specialty practice and used self-reflection regularly to identify strengths and weaknesses in their knowledge or thought processes to guide their ongoing self-improvement. The expert did not “blame the patient” if a treatment did not go as anticipated. Rather, the expert reflected deeply about what he or she could have done differently that would have allowed the patient to succeed. Expert Practice in Geriatric Physical Therapy. The geriatric clinical specialists interviewed by Jensen and colleagues each provided reflections about how he or she progressed from novice to expert. Figure 1-4 illustrates the conceptual model for the development of expertise expressed by geriatric physical therapy experts. In describing their path from new graduate generalist to geriatric clinical specialist, none of the geriatric experts started their careers anticipating specialization in geriatrics. They each sought a generalist practice experi￾ence as a new graduate and found themselves gradually gravitating toward the older adult patient as opportuni￾ties came their way. They came to recognize the talent they had for working with older adults and were called to action by their perceptions that many at-risk older adults were receiving inadequate care. They became Clinical Expertise Virtue Knowledge Clinical reasoning Movement Virtue Knowledge Clinical reasoning Movement Student Novice Virtue Knowledge Clinical reasoning Movement Competent Virtue Knowledge Clinical reasoning Movement Master Professional development Philosophy of practice FIGURE 1-3 Developing clinical expertise: Moving from novice to expert practice. (From Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in physical therapy practice: applications for practice, teaching, and research. ed 2, Philadelphia, PA, 2007, Saunders Elsevier.) Types and sources of knowledge Mentors Patients Students Education Clinical reasoning Diagnosis and prognosis within disability framework Life span approach Motivation Management of multiple tasks Personal attributes Hunger for knowledge Do the right thing Energy Philosophy of practice Decision making Physicality Community Teaching FIGURE 1-4 Conceptual model illustrating the factors contribut￾ing to the development of expertise in geriatric physical therapy. (From Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in physical therapy practice: applications for practice, teaching, and research. ed 2, Philadelphia, PA, 2007, Saunders Elsevier. p. 105.)