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  3251 Riverport Lane
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GERIATRIC PHYSICAL THERAPY, THIRD EDITION ISBN: 978-0-323-02948-3

Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
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Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluat-
ing and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others,
including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.

ISBN: 978-0-323-02948-3

Vice President and Publisher: Linda Duncan

Executive Editor: Kathy Falk
Senior Developmental Editor: Christie M. Hart
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Mary Pohlman
Book Designer: Jessica Williams

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 Thrice again – for Nancy, Katie, and Nicole

Andrew A. Guccione

To my husband Al for his unwavering support and

encouragement; and to my children and grandchildren
who grow more precious every day
Rita A. Wong

To Patrick VanBeveren, my husband, partner and best

friend
Dale Avers
 CONTRIBUTORS

Alia A. Alghwiri, PT, MS Cory Christiansen, PT, PhD Andrew A. Guccione, PT, PhD,
PhD candidate Assistant Professor DPT, FAPTA
University of Pittsburgh Physical Therapy Program Deputy Director
Physical Therapy Department Department of Physical Medicine Health Services Research
Pittsburgh, Pennsylvania & Rehabilitation & Development Service
School of Medicine Department of Veterans Affairs
Dale Avers, PT, DPT, PhD University of Colorado Washington, DC
Associate Professor Aurora, Colorado
Director, Post Professional DPT Greg W. Hartley, PT, DPT, GCS
Program Charles D. Ciccone, PT, PhD, Director of Rehabilitation &
Department of Physical Therapy FAPTA Assistant Hospital
Education Professor Administrator,
College of Health Professions Department of Physical Therapy Geriatric Residency Program
SUNY Upstate Medical University Ithaca College Director
Syracuse, New York Ithaca, New York St. Catherine’s Rehabilitation
Hospitals and Villa Maria
Katherine Beissner, PT, PhD Rhea Cohn, PT, DPT Nursing Centers
Professor Health Care Consultant Miami, Florida;
Department of Physical Therapy Washington, DC metro area Adjunct Assistant Professor
Ithaca College University of Miami Miller School
Ithaca, New York Joan E. Edelstein, PT, MA, FISPO, of Medicine
CPed Department of Physical Therapy
Diane Borello-France, PT, PhD Special Lecturer Coral Gables, Florida
Associate Professor Program in Physical Therapy
Department of Physical Therapy Columbia University Barbara J. Hoogenboom, PT,
Rangos School of Health Sciences New York, New York EdD, SCS, ATC
Duquesne University Associate Professor
Pittsburgh, Pennsylvania Cathy S. Elrod, PT, PhD Program in Physical Therapy
Associate Professor Grand Valley State University
Richard Briggs, MA, PT Department of Physical Therapy Grand Rapids, Michigan
Hospice Physical Therapist Marymount University
Enloe Medical Center, Hospice and Arlington, Virginia Catherine E. Lang PT, PhD
HomeCare Assistant Professor
Chico, California Christine E. Fordyce, PT, DPT Program in Physical Therapy
Rehab Director Program in Occupational
Marybeth Brown, PT, PhD, FAPTA Gentiva Health Services Therapy
Professor Auburn, New York Department of Neurology
Physical Therapy Program, Washington University
Biomedical Sciences Claire Gold, MSPT, MBA, COS-C, Saint Louis, Missouri
University of Missouri CPHQ
Columbia, Missouri Home Health Agency Administrator Tanya LaPier, PT, PhD, CCS
Gentiva® Home Health Professor
Sabrina Camilo, PT, MSPT, GCS San Diego, California Eastern Washington University
Private Practitioner Cheney, Washington
São Paulo, Brazil

vii
viii CONTRIBUTORS

Paul LaStayo, PT, PhD, CHT Jean Oulund Peteet, PT, MPH, PhD Chris L. Wells, PhD, PT, CCS,
Associate Professor Clinical Assistant Professor ATC
Department of Physical Therapy Department of Physical Therapy and Assistant Professor–Part Time,
University of Utah Athletic Training Department of Physical Therapy
Salt Lake City, Utah Boston University College of Health & Rehabilitation Science
and Rehabilitation Sciences– University of Maryland School of
Carleen Lindsey, PT, MScAH, GCS Sargent Medicine
Physical Therapist Boston, Massachusetts College Park, Maryland
Bones, Backs & Balance
Bristol, Connecticut John Rabbia, PT, DPT, MS, GCS, Karin Westlen-Boyer, DPT, MPH
CWS Intermountain Health & Fitness
Toby M. Long, PT, PhD, FAPTA Visiting Nurse Association of Institute at LDS Hospital
Associate Professor Central New York Salt Lake City, Utah
Department of Pediatrics
Director of Training Barbara Resnick, PhD, CRNP, Mary Ann Wharton, PT, MS
Center for Child and Human FAAN, FAANP Associate Professor and
Development Professor Curriculum Coordinator
Georgetown University Sonya Ziporkin Gershowitz Chair in Department of Physical Therapy
Washington, DC Gerontology Saint Francis University
University of Maryland School of Loretto, Pennsylvania;
Michelle M. Lusardi, PT, DPT, PhD Nursing Adjunct Associate Professor
Professor Emerita College Park, Maryland Physical Therapist Assistant
Department of Physical Therapy and Program
Human Movement Science Julie D. Ries, PT, PhD Community College of Allegheny
College of Education and Health Associate Professor County, Boyce Campus
Professions Program in Physical Therapy Monroeville, Pennsylvania
Sacred Heart University Marymount University
Fairfield, Connecticut Arlington, Virginia Susan L. Whitney, PT, DPT, PhD,
NCS, ATC, FAPTA
Robin L. Marcus, PT, PhD, OCS Kathleen Toscano, MHS, PT, PCS Associate Professor
Assistant Professor Pediatric Physical Therapist Program in Physical Therapy and
Department of Physical Therapy Montgomery County Infant and Otolaryngology
University of Utah Toddler Program University of Pittsburgh
Salt Lake City, Utah Olney, Maryland Pittsburgh, Pennsylvania

Carol A. Miller, PT, PhD, GCS Patrick J. VanBeveren, PT, DPT, Ann K. Williams, PT, PhD
Professor MA, OCS, GCS, CSCS Adjunct Professor
Doctorate Program in Physical Director of Physical Therapy Services College of Health Professions and
Therapy St. Camillus Health and Biomedical Sciences
North Georgia College & State Rehabilitation Center The University of Montana
University Syracuse, New York Missoula, Montana
Dahlonega, Georgia
Michael Voight, PT, SCS, OCS, Rita A. Wong, EdD, PT
Justin Moore, PT, DPT ATC, CSCS Physical Therapy Department
Vice President, Government and Professor Chairperson
Payment Advocacy School of Physical Therapy Professor of Physical Therapy
American Physical Therapy Belmont University Marymount University
Association (APTA) Nashville, Tennessee Arlington, Virginia
Alexandria, Virginia
Martha Walker, PT, DPT
Karen Mueller, PT, PhD Clinical Instructor
Professor Physical Therapy and Rehabilitation
College of Health and Human Science
Services University of Maryland
Department of Physical Therapy Baltimore, Maryland
Northern Arizona University
Flagstaff, Arizona
 PREFACE

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

ix
x CHAPTER 12 Chapter Title Goes Here

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

x
PA RT
I
Foundations

1
 CHAPTER

1
Geriatric Physical Therapy
in the 21st Century:
Overarching Principles
and Approaches to Practice
Rita A. Wong, EdD, PT

INTRODUCTION KEY PRINCIPLES UNDERLYING

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

2 Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc.

 CHAPTER 1 Geriatric Physical Therapy in the 21st Century 3

Best available evidence 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
Patient
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
Clinical Patient presence or absence of a chronic health condition.
expertise/judgment preferences and motivations
Functional limitations associated with chronic health
FIGURE 1-1 Key elements of evidence-informed practice. conditions often lead to a vicious downward cycle with
increasing levels of disability leading to greater decon-
apply the appropriate interventions to best manage the ditioning that further decreases functional ability. These
problem. This is all done with clear and full communica- declines lead to secondary conditions associated with
tion with the patient to assure the goals and preferences chronic conditions and, often, to additional new dis-
of the patient are a central component of the develop- eases. Physical therapists can be particularly instrumen-
ment of a plan of care. tal in reducing the disabling effects of chronic disease
processes by promoting restorative and accommodative
changes that stop or reverse the vicious downward
Optimal Aging
functional cycle, allowing the individual to achieve
Rowe and Kahn4 first introduced the terms successful optimal aging in the presence of chronic health condi-
and usual aging in the mid-1980s as a mechanism to tions.
remind practitioners and researchers that the typical
changes in physiological functioning observed in older
adults (usual aging) are quite variable and generally
Slippery Slope of Aging
represent a combination of unavoidable aging-related Closely linked to the concept of optimal aging is the
changes and modifiable (avoidable) lifestyle factors such concept of a “slippery slope” of aging (Figure 1-2).
as physical activity, nutrition, and stress management. The slope, originally proposed by Schwartz,7 represents
Their perspective encourages practitioners to consider the general decline in overall physiological ability (that
that for many older adults, a substantial proportion Schwartz expressed as “vigor”) that is observed with
of apparent age-related changes in functional ability increasing age. The curve is arbitrarily plotted by decade
may be partially reversible with lifestyle modification on the x-axis so the actual location of any individual
programs. along the y-axis—regardless of age—can be modified
Ten years later, Rowe and Kahn5 provided further (in either a positive or negative direction) based on
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- 100
fully are (1) absence of disease and disability, (2) high 90
cognitive and physical functioning, and (3) active engage- 80
ment with life. Rowe and Kahn describe a usual aging
70
Vigor (percent)

syndrome as one in which suboptimal lifestyle leads to Fun

chronic health problems that affect function and thus the 60
ability to readily engage in family or community activi- 50
Function
ties. Improving healthy lifestyle is encouraged as a means 40
of achieving successful aging.
30
Although helping older adults avoid disease and Frailty
disease-related disability is a central consideration for all 20
health care practitioners, the reality is that the majority 10 Failure
of older adults do have at least one chronic health condi-
20 100
tion and many, particularly among the very old, live with
Age
functional limitations and disabilities associated with
the sequela of one or more chronic health conditions. FIGURE 1-2 Slippery slope of aging depicts the general decline in
overall physiological ability observed with increasing age and its
For this large group of individuals, Rowe and Kahn’s impact on function.  (Adapted from Schwartz RS: Sarcopenia and
model needs to stretch beyond the concept of avoidance physical performance in old age: introduction. Muscle Nerve
of disease and disability. Suppl5: S10-S12, 1997.)
4 CHAPTER 1 Geriatric Physical Therapy in the 21st Century

lifestyle factors and illness that influence physiological information that must be brought to bear on a clinical
functioning. decision. Several conceptual frameworks are presented
Schwartz has embedded functional status thresholds in Chapter 6 and integrated into a model to guide phys-
at various points along this slope. Conceptually, these ical therapy clinical decision making in geriatrics. The
thresholds represent key impact points where small model is grounded in the patient-client management
changes in physiological ability can have a large impact model of the Guide to Physical Therapist Practice8
on function, participation, and disability. These four and emphasizes the central role of functional movement
distinctive functional levels are descriptively labeled fun, task analysis in establishing a physical therapy diagnosis
function, frailty, and failure. Fun, the highest level, repre- and guiding choice of interventions. The enablement–
sents a physiological state that allows unrestricted par- disablement concepts of the World Health Organiza-
ticipation in work, home, and leisure activities. The tion’s International Classification of Functioning, Dis-
person who crosses the threshold into function continues ability and Health (ICF) model of disability9 are also
to accomplish most work and home activities but may incorporated into this model, using ICF language to
need to modify performance and will substantially self- communicate the process of disablement and placing a
restrict leisure activities (fun) because of declining physi- substantial emphasis on describing and explaining per-
ological capacity. Moving from function into frailty oc- sonal, medical, and environmental factors likely to en-
curs when managing basic activities of daily living able functional ability or increase disability.
(BADLs; walking, bathing, toileting, eating, etc.) con-
sumes a substantial portion of physiological capacity,
with substantial limitations in ability to participate in
Crucial Role of Physical Activity
community activities and requiring outside assistance to
and Exercise in Maximizing Optimal Aging
accomplish many home or work activities. The final Lack of physical activity (sedentary lifestyle) is a major
threshold into failure is reached when an individual re- public health concern across age groups. Only 22% of
quires assistance with BADLs as well as instrumental older adults report engaging in regular leisure-time
daily activities and may be completely bedridden. physical activity.10 Sedentary lifestyle increases the rate
The concept of functional thresholds and the down- of age-related functional decline and reduces capacity
ward movement from fun to frailty helps explain the for exercise sustainability to regain physiological reserve
apparent disconnect that is often observed between the following an injury or illness. It is critical that physical
extent of change of physiological functions (impair- therapists overtly address sedentary behavior as part of
ments) and changes in functional status. For example, the plan of care for their older adult patients.
for a person who is teetering between the thresholds of Exercise may well be the most important tool a
function and frailty, a relatively small physiological chal- physical therapist has to positively affect function and
lenge (a bout of influenza or a short hospitalization) is increase physical activity toward optimal aging. Despite
likely to drop them squarely into the level of “frailty,” a well-defined body of evidence to guide decisions about
with its associated functional limitations. Once a person optimal intensity, duration, and mode of exercise pre-
moves to a lower functional level (down the curve of the scription, physical therapists often underutilize exercise,
y-axis) it requires substantial effort to build physiologi- with a negative impact on the potential to achieve
cal capacity to move back up to a higher level (back up optimal outcomes in the least amount of time. Underuti-
the y-axis). Lifestyle changes including increased exer- lization of appropriately constructed exercise prescrip-
cise activities may enhance efforts for an upward move- tions may be associated with such factors as age biases
ment along the slippery slope. Moreover, the further that lower expectations for high levels of function, lack
the person is able to move above a key threshold, the of awareness of age-based functional norms that can be
more physiological reserve is available for protection used to set goals and measure outcomes, and perceived
from an acute decline in a physiological system. A major as well as real restrictions imposed by third-party payers
role of physical therapy is to maximize the movement- regarding number of visits or the types of interventions
related physiological ability (vigor) of older adult pa- (e.g., prevention) that are covered and reimbursed
tients/clients to keep them at their optimal functional under a person’s insurance benefit. Physical therapists
level and with highest physiological reserve. should take every opportunity to apply evidence-based
recommendations for physical activity and exercise
programs that encourage positive lifestyle changes and,
Clinical Decision Making in Geriatric thus, maximize optimal aging.
Physical Therapy
The primary purpose of physical therapy practice is the
Objectivity in Use of Outcome Tools
enhancement of human performance as it pertains to
movement and health. Providing a framework for clini- Older adults become increasingly dissimilar with increas-
cal decision making in geriatric physical therapy is 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
 CHAPTER 1 Geriatric Physical Therapy in the 21st Century 5

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

therapist should be well grounded in the science of geri- specialty areas (orthopedics, neurology, pediatrics, geriat-
atrics and gerontology in order to be effective in making rics) using board-certified clinical specialists recommended
evidence-based clinical decisions related to older adults. 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
Clinical Expertise in Physical Therapy clearly describe the role each mentor had in their develop-
Clinical expertise is one of the three anchors to EBP. ment, whether for enhanced decision making, pro­fessional
Jensen and colleagues,13 through a series of well-planned responsibilities, personal values, or technical skill devel-
qualitative studies using grounded theory methodology, opment. Experts had a deep knowledge of their specialty
identified four core dimensions of expert physical thera- practice and used self-reflection regularly to identify
pist practice: knowledge, clinical reasoning, virtue, and strengths and weaknesses in their knowledge or thought
movement. These four dimensions provide a theoretical processes to guide their ongoing self-improvement. The
model to examine professional development from novice expert did not “blame the patient” if a treatment did
to expert. As depicted in Figure 1-3, the novice practitio- not go as anticipated. Rather, the expert reflected deeply
ner (physical therapy student) typically examines each about what he or she could have done differently that
dimension as a discrete entity. As professional develop- would have allowed the patient to succeed.
ment progresses, the practitioner begins to see the inter- Expert Practice in Geriatric Physical Therapy. The
relationships among the dimensions, with recognition of geriatric clinical specialists interviewed by Jensen and
overlap becoming obvious as clinical competence devel- colleagues each provided reflections about how he or she
ops. Expert practitioners describe these four dimensions progressed from novice to expert. Figure 1-4 illustrates
as closely interwoven concepts and explain their rela- the conceptual model for the development of expertise
tionships in terms of a well-articulated philosophy of expressed by geriatric physical therapy experts.
practice. The core of the expert physical therapist’s In describing their path from new graduate generalist
philosophy of practice is patient-centered care that to geriatric clinical specialist, none of the geriatric
values collaborative decision making with the patient. experts started their careers anticipating specialization in
This model for expert-practice professional develop- geriatrics. They each sought a generalist practice experi-
ment was examined for each of four physical therapy 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
Clinical Expertise
they had for working with older adults and were called
to action by their perceptions that many at-risk older
Virtue
Clinical adults were receiving inadequate care. They became
reasoning
Clinical
Virtue
reasoning
Types and sources Clinical reasoning
of knowledge Diagnosis and prognosis
Mentors within disability framework
Knowledge Movement Knowledge Movement Patients Life span approach
Students Motivation
Education Management of
multiple tasks
Student Novice
Personal attributes
Hunger for knowledge
Virtue Clinical Do the right thing
Virtue Clinical reasoning
reasoning Energy
Philosophy
of practice
Knowledge Knowledge
Movement Movement Philosophy of practice
Decision making
Physicality
Competent Master Community
Teaching
Professional development
FIGURE 1-3 Developing clinical expertise: Moving from novice to FIGURE 1-4 Conceptual model illustrating the factors contribut-
expert practice. (From Jensen GM, Gwyer J, Hack LM, Shepard KF. ing to the development of expertise in geriatric physical therapy.
Expertise in physical therapy practice: applications for practice, (From Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in
teaching, and research. ed 2, Philadelphia, PA, 2007, Saunders physical therapy practice: applications for practice, teaching, and
Elsevier.) research. ed 2, Philadelphia, PA, 2007, Saunders Elsevier. p. 105.)
 CHAPTER 1 Geriatric Physical Therapy in the 21st Century 7

firm believers in the principles of optimal aging and

Asking an Answerable Question
had a genuine high regard for the capabilities of older
adults if given the opportunity to fully participate in Converting a need for information into a searchable
rehabilitation. clinical question is the first step of an evidence-based
Geriatric experts are high-energy people who firmly approach. Taking a few moments to formulate a clear
believe in their role and responsibility as a patient advo- search question can considerably facilitate the search
cate, and they thrive on the challenge of the complex process. A poorly formulated question often leads to
patient who needs creativity and individualization of ap- frustration as thousands of possible pieces of evidence
proach, good interpersonal skills, and deep knowledge may be identified, most of which are only tangentially
of the specialty content. related to the real question. Strauss et al.2 identify four
These specialists model clinical excellence by not set- major components of a clinical question that should
tling for less than what the patient is capable of. Physical guide a search for evidence: the patient, the intervention
therapists are essential practitioners in geriatrics. The (or diagnosis/prognosis), the comparison intervention
physical therapist must embrace this essential role—and (diagnosis, prognosis), and the outcome. Some common
recognize the positive challenge—of mastering the man- themes when considering an answerable question related
agement of a complex and variable group of patients. to older adults are as follows:
Skill acquisition in any specialty area consists of
technical, perceptual, and decision-making components 1. The Patient. This component should narrow the search
during which the learner starts with uncomplicated stan- to an applicable subgroup of older adults. For exam-
dard situations and progresses to complex and variable ple, a clinician may be working with two different
ones. Performing in a highly complex and variable envi- patients, each with a diagnosis of spinal stenosis. One
ronment requires the highest level of decision making— patient is 92 years old and frail; the other is a very fit
typically mastered after the lower levels. Part of the transi- and generally healthy senior athlete. The best evidence
tion from novice to expert is the increasing ease with to guide the clinical approach to the frail older adult
which a person can enter a new and complex situation, with spinal stenosis is likely to be different from the
quickly (and increasingly implicitly) analyze the various best evidence for the senior athlete. Consider a more
components, and then make effective and efficient deci- complete description of the patient beyond spinal ste-
sions. Because the typical older adult patient is more nosis. For example, include modifiers as appropriate
complex and variable than the typical younger patient, such as community-dwelling or nursing home resident
the level of expertise required is particularly high. Less (institutional); well-older adult, generally healthy, or
experienced physical therapists should seek mentorship frail older adult; independently functioning or depen-
and residency opportunities and engage in active and fre- dent; young-old (age 60 to 75 years), old (age 75 to
quent reflection with peers to develop these skills. 85 years), old-old (older than age 85 years).
2. Intervention: This portion of the answerable question
represents the patient management focus of a ques-
FINDING, ANALYZING, AND APPLYING tion (therapy, diagnosis or diagnostic tool, prognostic
BEST EVIDENCE factors, etc.). The information delimiting the patient
Incorporation of best evidence into clinical decision section will help to focus the evidence on the unique
making is the second major anchor of evidence-based considerations of the older adult.
practice. We live in an information age. For almost any 3. Comparison intervention: A question about the ef-
topic, an overwhelming amount of information can be fectiveness of a given intervention or diagnostic pro-
accessed in seconds using computer technology. The cedure is often asking one of two questions: (a) “Does
challenge, as evidence-based practitioners, is to quickly a new intervention have better outcomes than the
identify and apply best evidence. The best evidence is commonly accepted usual care?” or (b) “Does a new
credible, clinically important, and applicable to the intervention have a better outcome than no interven-
specific patient situation. tion at all?” Either question may be important given
When faced with an unfamiliar clinical situation, a cli- the likelihood that alternative interventions are typi-
nician reflects on past knowledge and experience, and may cally available and recommended.
identify missing evidence needed to guide their decision 4. Outcomes: Carefully considering the specific out-
making. A four-step process is typically used to locate and comes of interest is a good way of focusing the
apply best evidence: (1) asking a searchable clinical ques- search for the evidence that is most useful in guid-
tion, (2) searching the literature and locating evidence, ing the specific episode of care. For example, does
(3) critically assessing the evidence, and (4) determining the primary question relate to the best approach to
the applicability of the evidence to a specific patient situa- remediate a key impairment, improve functional
tion. The following section describes each step in this mobility, increase the patient’s ability to participate
process and provides insights into applying these principles in activities, or improve overall quality of life?
in geriatric physical therapy. Typically, there are more studies addressing specific
8 CHAPTER 1 Geriatric Physical Therapy in the 21st Century

impairments and functional activity than participa- question. However, only a very small proportion of
tion and quality of life. evidence associated with the physical therapy manage-
ment of older adults is well enough developed to support
systematic reviews yielding definitive and strong recom-
Searching the Literature mendations. More commonly, best evidence consists of
Sources of Evidence. The scientific literature is divided the integration of the findings of one or several individ-
into two broad categories: primary and secondary ual studies of varying quality by practitioners who
sources. The primary sources are the original reports of incorporate this evidence into their clinical judgments.
research studies. Secondary sources represent reviews The evidence-based practitioner must be able to quickly
and analyses of these primary studies. The ideal evidence locate, categorize, interpret, and synthesize the available
source is a trusted resource that is readily available, evidence and also judge its relevance to the particular
easily accessed, and formatted to answer your specific situation.
questions quickly and accurately. Physical therapists Figure 1-5 and Box 1-1 provide an organizational
must be competent in finding and assessing the quality, schematic depicting the scientific literature as a pyra-
importance, and applicability of primary research arti- mid with foundational studies at the bottom of the
cles as well as being able to choose appropriate second- pyramid and the systematic integration and synthesis of
ary evidence from trusted sources. Geriatric physical multiple high-quality studies at the top of the pyramid.
therapy is a broad specialty area requiring an expansive The literature is replete with both foundational and
range of knowledge and clinical expertise and, therefore, initial (early) clinical studies (the first two levels of the
a wide variety of evidence sources. pyramid). Foundational studies provide theories,
As depicted in Box 1-1, each piece of evidence falls frameworks, and observations that spur empirical in-
along a continuum from foundational concepts and vestigations of topics with clinical applicability but, in
theories to the aggregation of high-quality and clinically and of themselves, have little direct and generalizable
applicable empirical studies. On casual review of pub- clinical applicability. Similarly, early empirical studies
lished studies, it is sometimes difficult to determine just provide direction to future research and suggest poten-
where a specific type of evidence falls within the con- tial impact but, by themselves, do not provide definitive
tinuum of evidence and a closer review is often required. answers to clinical questions.
The highest quality research to answer a clinical ques- Studies with a more definitive influence on clinical
tion (i.e., providing the strongest evidence that offers the decisions are higher up on the pyramid. High-quality
most certainty about the implications of the findings) is primary studies that examine typical patients under
typically derived from the recommendations emerging typical conditions and provide sufficiently long follow-
from a valid systematic review that aggregates numerous up are the most valuable in our search for best primary
high-quality studies directly focusing on the clinical evidence. These studies, termed effectiveness studies, are

BO X 1 - 1 Continuum of Evidence: Studies Representing Early Foundational Concepts Through

Integration of Findings Across Multiple Studies

Aggregation of the
Foundational Concepts Initial Testing of Definitive Testing of Clinically Applicable
and Theories Foundational Concepts Clinical Applicability Evidence

Descriptive studies Single-case design studies Well-controlled studies with high Systematic review and
Case reports Testing on “normals” (no internal validity and clearly meta-analysis
Idea papers (based on theories real clinical applicability) identified external validity: Evidence-based clinical practice
and observations) Small cohort studies (assessing • Diagnosis guideline
“Bench research” (cellular or safety and potential for • Prognosis
animal model research for benefit with real patients) • Intervention
initial testing of theories) Clinical trials,* phase I • Outcomes
Opinions of experts in the field and II • Clinical trials,* phase III and IV
(based on experience and
review of literature)

*Clinical trials:
Phase I: examines a small group of people to evaluate treatment safety, determine safe dosage range, and identify side effects.
Phase II: examines somewhat larger group of people to evaluate treatment efficacy and safety.
Phase III: examines a large group of people to confirm treatment effectiveness, monitor side effects, compare it to commonly used treatments, and further
examine safety.
Phase IV: postmarketing studies delineate additional information including the documented risks, benefits, and optimal use.
 CHAPTER 1 Geriatric Physical Therapy in the 21st Century 9

blood pressure also retrieves articles on hypertension).

In the “advance search” mode, you can limit your search
to studies focused on older adults (651) or, even more
narrowly, to individuals aged 80 years and above.
Aggregation
of clinically Or you can limit the search to studies in the highest level
applicable studies of the pyramid (randomized controlled trials, phase 3 or
4 clinical trials, systematic reviews). All these features
Definitive testing of make the search faster and more focused.
clinical applicability Cumulative Index of Nursing and Allied Health
Literature (CINAHL) is a database that focuses specifi-
cally on nursing and allied health. You must either pay
Initial testing of foundational concepts to subscribe to CINAHL or gain access through mem-
bership in a library or a professional organization that
subscribes to it. The CINAHL database is available free
Foundational concepts and theories
of charge to members of the American Physical Therapy
Association (APTA). The criteria for being indexed
in CINAHL are less stringent than PubMed. Thus,
FIGURE 1-5 Pyramid depicting the organization of scientific although there is an overlap with many journals indexed
evidence from low to high clinical applicability. in both databases, those indexed in CINAHL but not
PubMed tend to be smaller journals containing studies
more likely to be located lower on the pyramid with a
few and far between in geriatric physical therapy. The greater need to be assessed for design flaws that make
highest category of evidence (top of the pyramid) is a findings suspect. The search engine for CINAHL is also
systematic review of the existing literature performed less powerful than PubMed.
using unbiased and transparent methodology that Finding Full Text. Accessing through PubMed pro-
directly addresses the clinician’s specific question. vides an automatic link to the full text if it is available
Searching the Literature for Best Evidence. Locating free of charge. In this electronic era, most biomedical
evidence is typically a two-step process: (1) finding the journals (at least the volumes published over the past
citation and (2) locating the full text of the reference. decade or so) are accessed electronically either from the
Finding the Citations. The biomedical literature is publisher or from companies that purchase the rights to
cataloged and indexed according to their citations (title, include the journal’s holdings in a bundled set of jour-
authors, and identifying information about the source). nals made available to libraries and other entities for an
An abstract of the article is often provided with the cita- annual fee. Frequently, university and medical libraries
tion as well as information about how to access the full provide a link to PubMed directly from their websites.
text of the article and whether access is free or requires Accessing PubMed through one of the linked library
membership or payment of a fee. PubMed (pubmed. websites allows an immediate link to the full text of any
com) is generally the best database to use to search for articles that are available to library patrons. Members of
biomedical evidence. PubMed is a product of the United the APTA may similarly access a broad array of journals
States National Library of Medicine (NLM) at the through Open Door as a member benefit.
National Institutes of Health (NIH). This database Staying Updated with Evidence. Practitioners (across
provides citations and abstracts from an expansive list of all health care fields) are often unaware of new evidence
biomedical journals, most in English, but also including applicable to their practice, or ignore new evidence
major non-English biomedical journals. All journals because it is inconsistent with their accustomed
indexed in PubMed must meet high-quality standards, approach. Although both consumers and payers expect
thus providing a certain level of comfort about using practice based on valid evidence, the Institute of Medi-
PubMed-indexed journals as trusted sources. cine reports long lag times between publication of
The PubMed database can be searched online free of important new evidence and the incorporation of evi-
charge. PubMed provides a link to the full text or to a dence into practice.14
link to the publisher who controls access to the article if All health care practitioners should have a strategy to
there is a publisher-controlled charge for access. PubMed regularly review current evidence in their specialty area.
utilizes a powerful search engine organized to easily A simple review of the table of contents of core journals
narrow or expand a search as needed for efficiency. in the topic area can be useful. Core journals in geriatrics
PubMed provides many free online tutorials that help and geriatric physical therapy are listed in Box 1-2.
the user maximize their efficiency and effectiveness using In addition, choose one or two core journals in a pro­
this database. The Medical Subject Heading terminology fessionally applicable subspecialty area (stroke, arthritis,
(MeSH) used by PubMed also automatically searches for osteoporosis, etc.). It is a simple process to request
words that are known synonyms (e.g., a search of high the monthly table of contents of these journals; scan the
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