I NEED my lab coat pockets to carry my "tools of the trade" to perform my job tasks; specifically my goniometer, tape measure, reflex hammer, bandage scissors, gait belt and lastly my beeper. For me, my white lab coat serves 2 main purposes: to carry my so-called job tools; secondly, and to me most importantly, the white lab coat adds professionalism to my appearance. I constantly hear fellow therapists in the acute care setting (my hospital and others around the nation) complain we "get no respect" from fellow members of the health care team. I will be the first to say that just wearing a white lab coat demands respect, but I strongly feel that this does give a professional visual image in the acute care setting.

This became very apparent to me while I was visiting my 72-year-old uncle who had just undergone a total knee arthroplasty at a local hospital. A "cute little thing" as he called her, entered his room while I was visiting him two days following his surgery.  I recognized her as a PT solely by the gait belt around her waist. My uncle insisted I stay during his therapy session and I witnessed an appropriate and thorough treatment (THKA rehab in the acute care setting is my specialty practice) until the conclusion of the session.

My uncle asked if she remembered to "bring the measuring thing" (goniometer), stating she had forgotten it on all previous sessions. She patted the pockets of her scrubs & sadly informed him she had forgotten the device but would bring it tomorrow. After his discharge, my uncle informed me she "never did remember to bring her measuring thing" but he was very pleased with her care.

Likewise, he called me after his initial OPPT session at a private practice rehab clinic and told me his therapist was a "doctor of physical therapy" (as was his PT in the acute care hospital!). When I questioned him regarding what he liked most about his outpatient PT, he stated that he was "a doctor of therapy" and was "really smart." Both my uncle and his wife were very impressed that this therapist initially greeted them in the waiting room wearing a long white lab coat "just like my doctor" (which he wore only for the initial greeting & by their observation, did so for every new patient to his clinic-however, this made a lasting positive impression on my family members!). My uncle informed me that this PT used a "measuring thing that's called a gonio.. something") as soon as he arrived and frequently during each therapy session. By the way, his rehab was a complete success and he is doing extremely well following his TKA.

It is true that the acute care setting is vastly different from the outpatient setting but  all therapists can project a professional image at all times wherever we work; if a white lab coat contributes to this image, let's wear it!  Plus, we have pockets for all our "measuring things."

I have been a physical therapist for a long time and I had the opportunity of working in different settings. I have worked in places where my opinion did not count.  I have also worked in other places where my opinion was extremely valuable and respected, not only as a professional, but also as a human being. I worked in places where questions were not about the physical therapy scope but rather where the physical therapy office was a vehicle of blame for failure of other specialties.

Currently, I work in a facility where everybody respects the other person's opinion. From the highest person in the company to the lowest one, each and every of us have a word. We do have protocols that we need to abide like in any other facility. However, everyone in the office treats others with respect, both as professionals and as people, making work both enjoyable and rewarding. In this facility, we know that we will be dealing only with what we are trained to: the patient's improvement and quality of life.

The physical therapy profession got to a point where we also need to advocate for ourselves. Because of the shortage of physical therapists, salary is not the decision point for changing or maintaining your job. We need to look not only for the salary and benefits, but also if the facility is suitable. You have to consider if they will respect you as a professional and as a human being. If you are comfortable where you work, you will definitely have better productivity, and your patients will improve significantly.

One such "technique" is corrective exercise. Do you know the difference between corrective exercise and PT? I doubt if the general public can or will differentiate between PT and corrective exercise when it comes to seeking services. However, I'll try to be your eyes and ears on fitness "techniques" that are relevant to PT.

Corrective exercise is generally defined as comprehensive exercise that serves to improve functional movement, "perfect postural position" and correct muscle imbalances.  Individuals who provide corrective exercise are referred to as corrective exercise specialists, personal trainers or fitness professionals. There have even been some new terminology twists with the rehabilitation title. Some individuals claim to treat pain. Some organizations claim to offer "proprietary clinically proven exercise programs." Corrective exercise is described by one organization as "falling somewhere between personal training and PT" and "focuses on fixing the cause of your pain." 

Paul Chek describes corrective exercise as a system he developed which entails postural alignment, motor learning, primal pattern development^TM (basically developing and replacing learned motor patterns),  advanced core conditioning and integrative health concepts (comprehensive structural evaluations of body parts).

According to those who provide corrective exercise, the process starts with "a personalized postural and movement evaluation, health history review and goal discussion." Isn't this PT repackaged? The process has a familiar ring to what I do everyday as a PT. The line between these two services seems blurred to me. At least two different organizations offer certifications. But is that enough to protect the public and provide the service? 

I'm unsure what profession was left undefined between personal training and PT. But, if I'm to recommend a corrective exercise, does that not imply that a dysfunction, problem, disorder or deficit has been identified through an evaluative process? Once identified, is that problem, pain or deficit not then diagnosed? Therefore, if a deficit or problem is being corrected, doesn't that make corrective exercise a treatment? 

This leaves me to seriously wonder by conducting a health history review, identifying a misalignment or imbalance, which is essentially a diagnosis, forming goals and then developing a personal corrective exercise program, also a treatment of the problem, whether corrective exercise is really "between" personal training and PT or is it dead on PT? I think this is clearly defined in our scope of practice which falls under our license to practice.

Now that we have a better understanding of what corrective exercise is should we do something about it? Learning some of the marketing techniques used by the fitness industry might help capture or establish another service line for our practices. We as a profession could, if we don't already possess these skills, increase our exercise armamentarium with a little pizzazz such that consumers are as willing to pay and exercise with us.

Lastly, we could decide to act on attempts to encroach upon our profession. Knowing that encroaching upon PT practice is accompanied by consequences might deter some from going beyond their scope. How often do you find people trying to perform surgery in their basement? I would guess that does not happen often. Most people know if you're not a physician you can't pretend to do what physicians do without encountering some negative consequences.

So give it away, sell it or delegate it, but can someone just take a firm stand? It's tough to be undercut after you have invested a fortune to become a professional and need to make a living doing it so that you can get a return on your investment.

The SNF where I am currently employed does not have an aide to assist PTs. When a patient is treated, I must wait for another PT to assist me or attempt it myself. I have found the Lite Gait to be helpful. The challenge with the Lite Gait is getting the patient into the harness. It is usually a two-person job. Once the patient is in the harness, then it is safe to work a patient alone. However, some patients need two therapists: one to cue the trunk and one to assist with the hemiplegic lower extremity. 

Another challenge is getting the GNAs to lift correctly or not at all. In the SNF where I am employed, there are hoyer lifts and sit-to-stand lifts. There is also a pivot disc. Yet I find the aides reluctant to use this equipment. There is only one lift on each unit and the staff does not want to take the time to get the equipment.  Also the staff finds it faster to hoist the patient up and swing them over to the wheelchair.  This is a disservice to the patient because the patient is being treated like a sack of potatoes and the patient is at risk for injury. This is also a disservice to the GNAs, because one day their backs will pay the price.

Banner Health in Colorado implemented a safe lift program in 2001 that included mechanical lifts and overhead lifts. Banner Health had a 90 percent reduction in employee lift/transfer injury claim cost.  North Colorado Medical Center is also a no lift facility. North Colorado Medical Center went from 60 claims a year to seven claims a year. 

I believe that PTs in SNFs need to be aware of the "cost" of lifting patients. There is a cost to the therapist in regards to back injury. There is a cost to the patient (i.e. skin tears, dislocations, bruising, lack of dignity and other injuries). There is also a cost to the facility, such as employee turnover and workmans comp claims. Please try to educate your fellow employees and employer regarding a switch to a no lift policy.

In the lecture course I present called "Comprehensive Strategies for the Medically Complex Patient" I speak of the importance of the first 30 seconds of the treatment. The first 30 seconds of therapist/patient contact is going to make or break you depending on how you approach your patient. This is a crucial time in which you need to develop the patient's trust in you as a professional.

I use the following recommendations:

1) Knock and announce yourself, wait for them to reply, if they don't, knock again!

2) Acknowledge the patient and greet them with an introduction of yourself.

3) Get on their level. If they are lying down, ask to pull up a chair and sit next to them.

If they are in a wheelchair, kneel down so you can speak to them eye to eye. Imagine what it must be like to be in a wheelchair looking up at everyone's nose hair!

4) Establish touch. This is crucial in getting the patient's attention and bringing their attention to you. If they are hard of hearing or preoccupied by Wheel of Fortune--or worse, Jerry Springer--a simple touch will let them know you are there for them.

5) Ask the patient, "how are you doing today?" Then stop talking and LISTEN! It amazes me how many therapists are in a hurry and miss this part. By being quiet you allow the patient to vent frustrations, problems and concerns. This allows the therapist to figure out what they can or can't help with. If it is something like needing pain meds or finding a lost sweater, the therapist can usually fix this issue quickly.

We as clinicians have the gift of being able to empower the patient and turn their needs into part of the treatment. We can have the patient get out of bed and walk to the nursing station to ask for their pain meds or walk to the laundry area to look for their sweater. By doing this we are able to alleviate the distraction that may get in the way of us having a good treatment and win the trust of your patient for helping them solve their problem. Win win.

How about adding one more ingredient to this mix-an objective measurement?  I was fortunate to spend some time at Kuwait University as a visiting professor in the Physiotherapy Department and had the opportunity of implementing this approach to assessment/treatment. 

My primary role in Kuwait was as a researcher, but I also taught the pathokinesiology course during which I had the students objectively measure functional tasks. The lecturer responsible for the orthopedics section of the curriculum was interested in tests that could be used to objectively monitor progress in her patients. One of her patients had recently undergone a total hip replacement. During the surgery, her femoral nerve was compressed to the point that there was no nerve conduction. We went to the orthopedic hospital to visit this patient who was being treated by one of the students from the pathokinesiology course. Because of the loss of quadriceps activity, the patient was having difficulty going from sit to stand, sitting down and going up and down stairs.

It was decided to include these tasks as part of the treatment regime. This was done by having the patient walk up and down the set of stairs in the gym and undertaking the Timed Up & Go Test. Every two weeks, these tasks were timed with a stopwatch. The student then graphed the results, in much the same way as a nurse would chart temperature. The numbers and the graphs showed clear improvements being made much to the delight of the student and the patient. The student used the data to set goals for the patient and from the data the patient could see how close she was to achieving those goals.

If you think about it, this process is very similar to that used in athletic endeavors such as swimming. The coach (therapist) will watch the athlete (patient) swim and give advice and feedback to help the swimmer improve. While doing this, the coach will also be using a stopwatch to obtain an objective measure to determine if the athlete is improving. 

Standardized tests such as the Timed Up & Go Test are extremely useful because there are published studies on their reliability and validity, as well as normative data that can be used as a basis for comparison. However, individualized tests are also useful. A therapist working in home care might set a functional goal for the patient to be able to walk from his/her bed to the bathroom. To meet this goal the patient will have to be able to walk the set distance and do this in a functionally appropriate time. The stopwatch would provide information on how well the patient performs this task. If treatment is undertaken to improve walking, the time to walk from bedroom to bathroom should improve. This objective, ratio level measurement may be just what is needed to provide feedback to the patient and therapist to help set goals and to unequivocally document progress, or lack thereof. 

In life, sometimes we take even the simplest things for granted. In therapy, it is no different. Take, for instance, manual muscle testing. Manual muscle testing is one of the first skills we learn in school. It is a universal measure, understood by not only physical therapists and physical therapist assistants, but by occupational therapists and doctors. Manual muscle testing requires no additional equipment and a complete assessment can be done quickly.

Why is it then that so many therapists do it incorrectly?

So many times when reviewing charts have I come across strength assessments saying, "4/5 throughout," "5/5 throughout," "WFL" or "WNL." Rarely does anyone, much less an elderly patient, have uniform strength throughout, and if a patient has strength "within functional limits" or "within normal limits" why do we need to see these patients?

By doing incorrect assessments, therapists are setting themselves up for failure should they need to justify extended care or in an appeal of a denial. It is understandable that during an evaluation therapists have limited time, but that is no excuse for giving incorrect information. Decreased muscle strength is associated with too many functional deficits to be evaluated poorly. The evaluation is the groundwork for establishing the treatment plan and for communicating patient needs to successive therapists. With expressions like WFL, WNL and 4/4 or 5/5 throughout, another therapist will be unable to determine what exercises are most appropriate without doing another re-assessment, which is a complete waste of time. 

The most common errors seen in muscle testing are in the lower extremity, especially hip abduction, hip extension and plantar flexion. Hip abduction is tested side lying with resistance just superior to the ankle. Most therapists give resistance just superior at the knee. Hip extension is tested prone; if a patient can not achieve the prone position, a grade above 2/5 should not be given. And finally, to score a 3/5 for plantar flexion a patient needs to be able to perform a single-legged heel raise and few of my patients can do this.

Now, whenever I see the abbreviations "WFL" or "WNL" I take them to mean "We Forgot to Look" or "We Need to Look."

When lecturing many physical therapy assistants, they have asked, "What if I work with a PT who does manual muscle testing wrong?"  My recommendation is to approach the offending therapist, in a non-confrontational manner, and ask them to show how they grade muscle strengths as your assessments are completely different. As evaluating physical therapists, we should be trying to ensure that another therapist or assistant never has to have us explain how we grade muscle strength.

Therapists need to take the time to occasionally return to the fundamentals. The fundamentals are the basis on which all of our treatments are built upon and we need to make sure that we don't take even the simplest things in life for granted.

As I went over this information, I stopped to reflect on my earlier experience in the clinic that day. I was working with a therapist who feels she is an expert; which can be a good thing when limits and mutual respect are present. In her case, it is not. She feels she stands as an expert on an island all by herself and I explained this to my students. I also explained how this type of attitude is death for our profession. I then relayed what had happened that day because of this therapist's attitude which impeded patient care.
I had seen an 84-year-old woman with back pain. I felt a major contributor to this pain was an SI (sacroiliac) involvement. I mobilized her and showed her how to do self mobilizations for this. She came in with a pain of 8 and left with a pain of 4 on a 0-10 pain scale. I had to leave the rest of the week to teach and gave her to my fellow therapist.

On the next visit my patient relayed her improvement and her love of the self correction technique to this therapist. The therapist immediately stopped the exercise because she felt it was not good. My patient came in one more time that week and was put on a stabilization program. When I finally saw the patient the pain had increased to a 6 and she was wondering why she had to stop the exercise that was helping. When I approached the therapist, I was told she had extensive training in treatment of the SI and did not believe in self correction and refused to discuss it. Needless to say, I left it at that. The patient now refuses to see this therapist when I am gone and my hope is this therapist might question why, which I doubt will happen.

I told my class that the reverse situation had also happened to me. With this same therapist, several months ago I treated a younger patient (65 years old) and what the other therapist had done after my treatment really helped. I was excited to ask the therapist what she had done and I enjoyed using her ideas to help heal this patient in subsequent visits.

Being an expert is not being a know-it-all or a zealot. We need to get over ourselves. Who is teaching therapists to have this kind of attitude? I told my class if I ever become this myopic and self centered to just take me down a notch. We can all learn from each other. But how do you teach that and how do we get therapists that already have that air about them to come down to earth?

We need good geriatric experts because of sheer impending numbers alone. Any ideas on how to make this happen would be great. Thank you. Let me learn from you.

Carole Lewis DPT, PT, GTC, GCS , PhD, FAPTA

However, use of these assistive devices during the final aspects of the rehabilitation process can cause some difficulties. The goal of rehabilitation is to return the individual to the prior level of function. Most individuals did not need an assistive device before entering the hospital due to an elective surgery such as total hip replacement or due to an illness such as a stroke.

During the rehab process, in the name of functionality or in order to satisfy the insurance companies, we give them an assistive device to help with their mobility and to discharge the individuals sooner. However, some individuals get attached to the assistive device and are never able to wean from it. Even if they do not need the device later on, they still hang onto it as their "security blanket."

On the other hand, there is the problem with lawsuits. If we do not offer the assistive device and the patient happens to fall later on, it will be our fault and we may be sued. In other countries, most of the individuals that are in a rehabilitation program do not receive an assistive device. The rehab goal is towards returning the patient to the prior level of function, which eliminates the use of assistive devices. Even if the process is longer, the treatment plan is based on improving level of function and not relying on different equipment.

Patients do fine and they learn how to walk, stand and perform their activities of daily living without using an assistive device. So the question that comes to mind is: Do we really need to prescribe an assistive device for all patients in the acute and subacute rehab that have balance and gait problems? Or should we work with the patient in order for them to regain the functional independence without the equipment? 

Just over a year ago the private practice I was working for was sold, and I found myself in unfamiliar territory. Was it time to go out on my own? Should I take a staff job in a larger clinic, or look to practice in a different setting?  During my search for my next job, I was offered a position at a physician owned practice (POP), by referring doctors to the practice I had previously worked for.

This presented a bit of a moral dilemma--I had been working the majority of my career with the mind-set that POP's go against our professions independence. I fully believe that physical therapy is an integral, yet independent part of health care. If I went to work for a POP would I be going against my core beliefs as a therapist?

I interviewed at multiple sites, different practice settings, and with various contract companies.  When it came down to decision time, I signed a year contract with the physician owned practice. In the end my decision was not that difficult. It was financial. The offer at the POP was substantially better than any other offer. So, I am nine months into my year at the POP and here are my thoughts in a nutshell. 

The positives: I make more money and I am required to see fewer patients per day. I am not required to market. I do not have any administrative responsibilities. There is no delay in care due to prescription requests. There is more money available for continuing education. I believe the physicians are better aware of what physical therapy can do for their patients. Overall, because I am required to see fewer patients and have few administrative responsibilities, I feel like I am able to spend enough time with each of my patients to ensure they are getting the best care that I can give.

As with any situation, there are negatives: The billing staff is used to physician billing rather than physical therapy billing, so there are times when avoidable mistakes are made. As a physical therapist, we are treated as all other staff members meaning that our opinions are not solicited in the day to day running of the physical therapy department. Our supervisor is not a therapist, and some of the decisions made for the entire practice do not have the therapists' best interest in mind. Also, there is little motivation to be involved with our professional organizations from the company as a whole.

Overall, I think it depends on the priorities of each individual. In my experience, working at a POP provides easier day to day work focused almost exclusively on patient care. It doesn't provide an environment to promote our profession as a unique and necessary entity in health care. I worry that if POPs become the way of the future we will, as a profession, lose our independence.

I haven't decided what my next move will be, but I think my days at the physician owned practice are numbered.  Until then, I will continue to ask myself everyday "did I sell-out?"

I am led to those questions when I regularly see consumers opt for services from fitness professionals and not physical therapists even when they need rehabilitating.  I recently did a radio interview and I was asked to define for the audience the difference between a physical therapist and personal trainer.  Have we put ourselves in the situation of only being there when someone has surgery, an injury or a stroke but don't call us when you're well or want to be better than what you are? 

Those same questions come to mind when I see print, web, radio and television media feature stories about ergonomics, pain relief, corrective exercise and addressing muscle imbalances without even the slightest mention of a PT.  So are we being neglectful in one of our responsibilities to educate the public about who we are and how we are different from other professions? 

Apparently we are only thought of when rehabilitation is needed but not to prevent injuries, maintain fitness or wellness.  Consumers seem to think of us as reactive and not proactive.  I've been told by consumers that they "go to the PT if they're sick and the trainer if they're well." 

Just last week, my local news ran a story on "How to eliminate pain and muscle imbalances with a new technique."  The featured technique was Muscle Activation Technique.  The featured professional was a personal trainer "certified" in Muscle Activation Technique.  Of course the fitness industry and even wellness is associated with wellness, beauty, energy and youth.  Some consumers think fast fix, results and a different environment versus that which they see in a typical outpatient clinical setting.  It simply seems more appealing.  I've had friends, family and everyone in between ask "what can physical therapy do if I'm not sick?"-my trainer says he can do that for me.  I recently heard of one person who told a PT his trainer could assist him in the gym to work his injured rotator cuff.

Truth be told, yes, I'm a trainer. But I have to separate the professions while recognizing areas that really would benefit from improvements.  At no point in time as a trainer did any client ever ask for evidence that showed what I would do for them that would get them their desired outcome.  They never winced at my charges.  Rarely if ever did they no show.  They were willing to do whatever I suggested if they thought for an instant it would get them closer to their fitness goals.  Yes, they stuck with it if it worked, but the burden of proof was never brought up.

So now trainers are "learning" self-myofascial release and using it with clients completely unregulated and without any standardized education.  One organization which has actually taught self-myofascial release is actually owned by a PT.  Now, there are corrective exercise specialists which do even more by their claims.  I suspect if you find something to correct you must have evaluated the person first in order to determine what needs to be corrected which would then be a treatment. 

Trainers have access to our medical devices such as electrical stimulation that they can order online, our text books and can even attend our continuing education courses sometimes.  Does the consumer know how to differentiate between the two professions?  Is there a tool or source they can refer to in order to assist them in making the decision?  All of this is going on in your backyard.

Please accept these observations in the spirit in which they are being provided.  I come from a place of wishing for and appreciating an educated, evidenced based integrative approach to actively seeking wellness by taking advantage of what both professions have to offer.  Fitness professionals have a very important role in some of our patient's lives and for that I'm appreciative.  However, the fitness professionals will do more and more of our jobs if we don't educate ourselves about the fitness industry and educate the consumers that we are experts in movement best trained to work with them by the application of sound evidenced based practice.

Making ourselves more approachable and attractive to the general consumer so they see us differently may be a step in the right direction. So the next time the local news covers Muscle Activation Technique, myofascial release, and ergonomics they will include a PT.  Write a consumer article in your local newspaper or consumer magazine.  And, managers, yes! We need time to do it.  There is more to our profession than just patient care.  We need visibility that's non-clinical among consumers. Otherwise our patient base may erode right under our noses.  You may find that a little media coverage may go a long way when it comes to patient's seeking your clinic out for care.  We could stand to learn something from the fitness industry when it comes to public relations and marketing.

Be an ambassador for physical therapy and protect the profession you worked so hard to be a part.  Embrace your fitness professionals.  Maybe learning from you will show them how to be good at what they do without trying to do more than they should so we protect the consumer.

So, integrate, educate and communicate.

Where is therapy going? As an area manager in Northern California and a lecturer on geriatrics with Great Seminars, I am shocked at what I am seeing out in the field.

Before we used to have therapists practicing with longevity at one place. These therapists are the ones who have maybe one or two jobs during their career. The model has changed since PPS (Prospective Payment System).

During the beginning of PPS, we ran a lot of good therapists out of therapy. Once that happened, therapy rebounded and we had a shortage of therapists to treat our elderly. On top of that, schools began shutting down or limiting enrollment, causing an increase in demand for therapists. With our country's high need for therapists, we have been able to offset the demand by foreign-trained therapists.

Now we are faced with another problem, we are seeing what I like to call the "hired gun therapists." In the old movies, the hired gun would pay to come in and help out. Now a days, these are the therapists that have no loyalty to the company or the facility they work in. They are out there working for the highest paying company. They come in, do their work and leave. This hired gun therpy has continued to increase the strain on our therapy services.

I get between three to five calls a week at home from recruiters offering great sign-on bonus and salaries. Recruiters call therapists at home as well as facilities to try to lure them out. By doing this, it causes a increased demand on the companies tryng to deliver good therapy.

We are constantly battling to retain employees and at some point the bubble is going to burst. We are having one- to two-year therpists demanding high wages--as much as, if not more than, we are getting reimbursed for by medicare per hour. The sad thing is someone will hire the "gun slinger" for the price they want in order to fill the position to get their patients treated.

One repetition maximum (1RM) strength training is considered the gold standard in terms of improving strength.¹ It is effective for frail elderly ², more effective than aerobic endurance training for glycemic control in diabetic patients³, can help improve depression⁴, is safe an effective for cardiac patients⁵  and for COPD patients^6,7and can actually help decrease use of the health care delivery system.⁸ So when therapists strength train elderly patients, one repetition maximum principles should be applied, right? Unfortunately, the answer is no. Strength training is rarely used in rehab of elderly patients.

There is no excuse for not using 1RM principles every time therapists apply weights to their patients.  There is an extensive list of studies that show that 1RM strength training is the MOST effective way to improve strength not only in the elderly but in all age groups. The most recent studies are now, not trying to prove that 1RM is effective but which variation is the most effective. For instance, is 1 time/week as effective as 3 times per week and/or is 1 set as good as 3 sets.  Unfortunately for our patients this research will be wasted unless therapists start using 1RM in their practice.

With the onset of PPS and Part B caps, therapists need to ensure that their treatments are efficacious and efficient. Medicare and other payors are also expecting skilled therapy treatments. 1RM does both. In 2 to 3 short treatments per week, tremendous strength gains can be made and treatments will be skilled and effective.

For the elderly, not only is it unskilled but also unsafe to apply random weights. Take for example, osteoporosis. Because muscle strength is comparable to the degree of muscle loss, it is safe to assume that whatever the muscle can tolerate, the bone can tolerate. Putting a random amount of weight on the distal end of an extremity might be enough force to cause an occult fracture or possible damage to the muscle or tendon. In addition, random weight application for strength training IS NOT SKILLED!

How do you do 1RM strength training? Use the Oddvar-Holten diagram. 

Oddvar-Holten Diagram

Reps    Percentage of Intensity

1 -------------100%

2 -------------- 95%

4 --------------90%

7 --------------85%

11 -------------80%

16 -------------75%

22 -------------70%

25 ------------ 65%

30 ------------- 60%

Take the weight of the repetition and divide it by the percentage of intensity at the number of repetitions that patient can do to fatigue. For example, if a patient can do 10 pounds 16 times (75%) then, divide 10 by 0.75 for a 1RM of 13.3 pounds. For a safe and effective exercise program for an elderly patient multiply the 1RM by 80%. In this case 13.3 times 0.80 equals 10.5 pounds. Have the patient do 3 sets of 10 at 10.5 pounds every other day and enjoy the results.

Therapists, in general, are in favor of evidence-based practice but are reluctant to change their treatments. If therapists continue to discount research as to the effectiveness of this exercise modality, then we will have only ourselves to blame if other professions take our skill.

So in this year of the Olympics, let us all set a goal to go for the Gold-the gold standard of strength training and of anything we do for our profession.

References:

1. Levinger I. Goodman C. Hare DL. Jerums G. Toia D. Selig S. The reliability of the 1RM strength test for untrained middle-aged individuals. J Sci Med Sport. 2007 Dec 8

2. Cauza E, et. al. The relative benefits of endurance and strength training on the metabolic factors and muscle function of people with type 2 diabetes mellitus. Arch Phys Med Rehabil. 2005 Aug;86(8):1527-33.

3. Blumenthal JA, et. al. Effects of exercise training on older patients with major depression. Arch Intern Med. 1999 Oct 25;159(19):23

4. Karlsdottir AE, Foster C, Porcari JP, Palmer-McLean K, White-Kube R, Backes RC.
Hemodynamic responses during aerobic and resistance exercise.  J Cardiopulm Rehabil 2002 May-Jun;22(3):170-7

5. Panton LB, Golden J, et. al. The effects of resistance training on functional outcomes in patients with chronic obstructive pulmonary disease.  Eur J Appl Physiol. 2004 Apr;91(4):443-9

6. Kongsgaard M, Backer V, Jorgensen K, Kjaer M, Beyer N.  Heavy resistance training increases muscle size, strength and physical function in elderly male COPD-patients--a pilot study. Respir Med. 2004 Oct;98(10):1000-7.

7. Phillips SM.. Resistance exercise: good for more than just Grandma and Grandpa's muscles. Appl Physiol Nutr Metab. 2007 Dec;32(6):1198-1205.

8. Stevenson K, Lewis M, Hay E.  Do physiotherapists' attitudes towards evidence-based practice change as a result of an evidence-based educational programme? J Eval Clin Pract. 2004 May;10(2):207-17.

What a life! I have been blessed with the rare opportunity to be able to teach about my passion as a physical therapist: Geriatrics. I remember a saying that went like this, "You can be prejudiced against other races and religions but you cannot be prejudiced of the elderly for someday you will be one." Yes, some ripe old day I will have the pleasure or displeasure of being a geriatric/baby boomer.

In the course I teach, "Comprehensive Strategies of the Medically Complex Patients," I am able to share with others the changes that are coming in the future. Our Baby Boomers are getting older and we are embarking on an amazing journey. Some quick facts for you:

• The baby boom generation was from 1946-1964;
• Age of oldest baby boomer in 2006: 60;
• Number of baby boomers: 78.2 million;
• Number of people turning 60 each day in 2006: 7,918;
• Percent of women among baby boomers: 51 percent.*

With this population getting older and placing a heavy demand on our medical system, it is important as a therapist to position ourselves to be experts in the field.

We need to start making the connection to the literature out there and apply it to our setting. When I ask therapists in the class, "How many people have read an article regarding therapy in the last month?" Out of 115 people, five had looked at a therapy article.  

This concerns me; with the increase in technology and the high-tech world we live in, we need to get on our computers and access the super highway of information available at our finger tips.

Therapists need to continue to stimulate their brains and ask why they are treating the way they are. If we don't, we end up becoming what I call "flat line therapists." These are the therapists that get up in the morning and go to work and do the same type of treatment everyday with their patients. When you review their notes, they look like they have just copied the prior day's treatment down. This type of therapy is what causes Medicare to question our "skilled intervention" and causes a high burnout among therapists.

Ask the question "Why?"

* Census Bureau

I recently saw an item in the news where a reporter was interviewing an obviously excited resident of a retirement home. The reporter was doing a story on the elderly and their use of a video game system called the Wii made by Nintendo. 

Video games played on devices, such as the Microsoft Xbox 360 or the Sony PlayStation, are typically controlled by pressing buttons or manipulating a joystick, or both. What makes the Wii unique is that the user interacts with the video game by moving a hand-held controller in three-dimensional space. 

Unlike the more typical devices that rely primarily on fine motor skills the Wii responds to gross movements of the arm and hand. So, for example, in the video game that simulates tennis, the player moves the controller in exactly the same way as you would a tennis racquet when making forehand and backhand shots. 

Nintendo had a strategy to market the device to the elderly, an untapped segment of the population for gaming devices. It appears as though this strategy is working, if the retirement home resident that I saw on television is any indicator. What sparked his excitement was that the games were really competitive and the residents loved them. 

Wii-based bowling is evidently one of the more popular games played by the elderly and all can participate. The more able can go through the movements you see everyday at bowling venues.  (Click here for more.)  But, people in wheelchairs can also compete, since it just the movements of the arm and hand that control the game.

This got me thinking about the blog that Dr. Carole Lewis wrote about motivation a few months back. In that piece she promoted the need for effectiveness of treatment as the basis for motivation. Effectiveness is reflected in outcome. The elderly that play Wii games know exactly how well they are doing because they get instant feedback in the form of a score. Improving on their score is what motivates them to do better and they get better by practicing.

If we exchange the terms "practice" and "score" for "treatment" and "outcome measure" then bingo, we have a model for effectiveness-based motivation for clinical practice. Of course, it wouldn't hurt to learn another lesson from the Wii experience, add a little fun to spice up the competition!