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Jun 5, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses three tips to give older adults permission to succeed in physical therapy: acknowledge their concerns, craft experiences that ensure success, and focus on belief change.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

JEFF MUSGRAVE
Welcome to the PT on ICE daily show. I'm going to be your host, Dr. Jeff Musgrave. This podcast is brought to you by the Institute of Clinical Excellence. It is Wednesday, so it is all things older adults. So excited to be here with you today. So even if you're not treating primarily older adults, I think you're gonna find a lot of value in today's topic. So today's topic, we're gonna be discussing permission to succeed. So this is very common in the older adult space, but you're gonna see this in lots of different populations that you're gonna be treating. where because of the interactions that older adults or any of your patients on your caseload have had, they've got a very negative outlook on their ability to recover, their ability to return to the things that they love. I've seen this across acute care all the way into the fitness realm. and especially people when they first come to us in the fitness realm for training as older adults in stronger life, they will need some encouragement. They will need some reframing of what is possible and reframing of how they see themselves. So I believe that you will not get the person physically if you do not first get them mentally. You have got to build that confidence in between their ears. They've got to see and understand a path forward before you're going to get the body on board. So I would love to share with you today some tips to make that just a little bit easier. I think a quote that really sets the stage for this discussion is from Dr. Justin Dunaway. We love to quote him in the older adult division and one of our favorite quotes of his is, beliefs and expectations are the foundation upon which outcomes are built. Beliefs and expectations are the outcome are the foundation upon outcomes are built. So we really have to believe that it's possible. We've got to know our patient's beliefs and we've got to set the stage for them to be successful. So, because our older adults have heard, you've got the worst case of, insert diagnosis, bone on bone, you've got degenerative disc disease, they've heard all these nocebos or noxious language that strikes fear in the hearts of our patients. Whether they're older adults or not, you're going to see this in younger populations too, but we see it a ton in our older adult population. So I've got three tips for you today to try to help move patients towards a mindset that's going to allow you to be successful.

ACKNOWLEDGE CONCERNS
So the first one is acknowledge. You need to acknowledge their concerns. Our older adults come with some baggage typically. They've lived more years, more decades, they've had more injuries, and oftentimes they've been told more negative things than our younger patients. They've been told You can't get better, or you'll never do X, Y, or Z again. Jog, run, swim, lift heavy things, insert the favorite activity that they love that is part of the reason they're living their life. This happens all the time, unfortunately. So, we need to hear those concerns. If it looks like we're running into a barrier where they think they can't do what your job is to help them do, we've got to ask some clarifying questions. We need this information anyway. Why do you think it's not possible for you to fully recover from this back injury? Is it a bad experience with physical therapy? Is it negative expectations that have been set from another provider? Is it an experience a friend or loved one had? And then you get the opportunity to find out what was their bout of care like? What type of treatment intervention were they getting? Was it even appropriate? Was it the right movement? Was it at the right intensity? Was it across the right duration? Was there such a huge disconnect between what they actually wanted to do and what they were being asked to do? that they didn't see the connection, they never did their home exercise program. There is so much we need to know about why they have the negative outlook that they have. And then you get the opportunity after hearing everything, because if you cut them short in this phase, you will not get them. If you don't hear all their concerns and why, you can't give them the information they need to help them bridge that gap from I can't get better to oh, maybe I can get better. You don't have to completely change their mindset in one or two visits. Unlikely you'll be able to do that anyway. What you need to do is inspire some curiosity. You need them to be curious about the possibility of getting better. If you can get them from, I don't think it's possible, to now I'm curious, you've cracked the door open and created just a little bit of hope. you may be wildly successful with this patient. So, once you've heard everything, you get the opportunity to share some success stories. And you can say, man, I hear you. I know you've been told by this provider, and I can understand based on what you've seen, based on your imaging, based on your past experience, why you would be concerned that maybe you can't overcome this. but I've seen people in your condition with this diagnosis at your age, maybe even older, maybe even less healthy than you, get over this. It's gonna take time, it's gonna take hard work and consistency, but man, how would your life be different? If you could bridge the gap to a full recovery, what would you do differently? How much better would your life be? Let's just be curious. We've got time together. Let's do this thing. So I would call that step one. Acknowledge their concerns, ask clarifying questions, share success stories. have to do that first. Let them get it all out. You want to know every objection they have so that you can tell them why they don't need to be concerned about that.

CRAFT EXPERIENCES THAT ENSURE SUCCESS
The second piece, your job is to craft. Your job is to craft experiences that ensure success. There are two ways that we commonly do this with older adults that I assure you work with younger adults as well. The first one is make it laughably easy. In the older adult division, we call this intentional underdosage. This could be because someone is fearful, This could be because someone just has very low confidence. This could be because they're in unfamiliar setting or they've never done any weight training before. You're getting to set the stage for them. And you can do that by building successful reps. You want to make it so easy there's no way they can fail. Ramp it up a little bit. Let them be successful. Oh man, that's awesome. You're stronger than I thought you were. Ramp it up a little more. Ramp it up a little more. But what you don't want to do here is get greedy. If you get greedy as a clinician, I've done this several times, where you're like, man, I think they can actually deadlift 100 pounds, let's see if we can knock that off the list on day one deadlifting. And then they get scared, they get fatigued, or maybe you just misjudged it, and they can't lift that up, and now you've ended on an unsuccessful rep. You've shot yourself in the foot. So when you make it laughably easy, you intentionally underdose, make it easier than what you know they can do, you want to stop short of their maximal capacity. typically on that first visit, unless you're calculating an estimated one rep max, which is a whole nother topic. If you're already familiar with estimated one rep max testing, that is not the same as intentional underdosage. We're talking day one, building confidence, okay? So that's how we're going to, that's the first way we can craft an experience to ensure success is to intentionally underdose. The second thing that we're gonna do is test retest. We're going to show them that we can be successful. We're going to identify the asterisk sign, the comparable sign, whatever you want to call it. Doesn't matter. Especially when the primary concern is pain. Often with older adults it's function, but sometimes it's still pain. So I don't know, you know, the reason I'm here is because I can't get my arm up into the top cabinets anymore. I get shoulder pain. I get stuck. It hurts. Your job as a clinician, after you do your assessment, you figure out their range of motion, their strength, you've done a solid subjective, you ruled everything out, you've got a pretty good idea of what's going on, you're gonna give them some treatment, and then you're gonna retest, right? You need to make it very clear, you need very accurate measurements, and you need to tell the patient, here's where you got to. Man, that was about here, wasn't it? and make it really clear to them. You want them to remember that first measurement because what you're going to do is you're going to make them better. You're going to use your voodoo, right? You're going to throw your darts. You're going to do some manual therapy. You're going to do some exercise. You're going to put all those components of a solid treatment together and then at the end, you're going to knock their socks off, right? They thought that their shoulder could never get better. They've already been to PT several different times or it's been 10 years since this has been going on and you're going to show them. You're going to crack the door open on a successful recovery, just enough to at least make them curious. Test, retest. So when you craft that experience, you've got two solid options here. You can Intentionally underdose, if you're looking at a strength or a functional goal, or you're gonna use test, retest. Make it very clear, be very accurate on both measurements. Make it super clear, make sure it's your asterisk sign. You're gonna show them success. You're gonna give them the experience of being successful when they walked in the door and thought they could not be successful.

FOCUS ON BELIEF CHANGE
And then the third thing, once you've done that, you've still got work to do. You've got to focus them. You're going to have to focus them. You're going to have to refocus them throughout the entire bout of care. These beliefs go deep. They've been going on for a long time. You're going to have to chip away at those across the entire bout of care from the first interaction to the last one. Okay, especially if these beliefs have been long standing. So once you, the bedrock of changing their beliefs is giving them a successful rep and then reminding them of that success. You would think it would be obvious. There are so many client interactions where I did not do a good job of sharing. Remember, here's where we started. You can only slide your hands down to your knees when you came in and you had searing pain down your leg. And then they're at mid-shin, or maybe almost they're touching their ankles in the first visit. When that is their comparable sign, they're like, oh no, I moved that much. like you absolutely did not, but I did not make it clear enough what was going on at the beginning to show you how you progressed. So you need to make that painfully clear. After that, you need to remind them of their progress. Each visit, remember where you started. Remember where you started. The first day you walked in, you thought that it was going to be impossible to lift up this 10-pound weight from an elevated surface. You looked at that weight. You stared at it. You looked at me. You looked back at the weight. You were like, this is not happening. And then what happened? You walked up, you moved that thing. You got several reps. We even got up to 15 pounds that first time. You didn't think you could do 10. You thought that was out of reach. Now you're lifting 30 pounds. 30 pounds. You have had a 300% increase in your functional ability. Incredible. Now you're doing it off the floor. Think about how that opens up your life. How many things in your life weigh 20 to 30 pounds? Now you're doing it for reps. Think about all the things you can do now that you could not then. And the reality is, our patients aren't gonna have this nice, linear progression. So the third step on focus is going to be to share with them, these are a couple of my favorites I like to use, is progress is non-linear. We like to think it's just going to go up and up and up and every visit is going to be a smashing success. It's going to be the most you've ever done. It's going to be incredible. But that is not the case. We know that it's more like a good stock in the stock market. A really solid stock has got down days. and your patients are going to have down days. Medically, especially with older adults, they tend to be more medically complex. If you've got a progressive neurological condition, you've got someone with MS, and they're going through an exacerbation, there may be two weeks where there's flatline progress or reduction, but if it's still above where they started, you need to highlight that. Yeah, but we're not where we started, and we know this is going to end. And then we're going to start climbing again. And when we back up and look at this picture, it's going to be off the charts. When we back up, we've still got a solid line going up that day. So the other quote is, every day is not going to be your best day. Come in and give me what you got. That gives our patients permission to do what they can. And sometimes that is enough to crack the door open on a really solid recovery. I love this quote. Now, I'll share it with you. It comes from a spiritual realm, so I'll share that and then I'll give you the bit for it. So, a man with an experience of God is never at the mercy of a man with an argument. A man with an experience in God is never at the mercy of a man with an argument. So, if we reframe this around our patient's beliefs and expectations, their argument of I can't get better, we're gonna chip away at that by producing these successful experiences, building on success. We're gonna chip away at those beliefs. It's like, man, I know you thought you couldn't do it, but you've already done it. You're already someone you didn't think you were.

SUMMARY
And that's what I've got for you, team. So three steps to give your patients permission to succeed. One, acknowledge their concern. You've got to listen well, ask clarifying questions, know all the barriers that are in your way, and you're going to push those out of the way with success, stories of sharing how you're going to be different. Second thing is you're going to craft successful scenarios. You're going to ensure success, whether it's an intentional underdosage or test-retest. You're going to show them what they didn't think could be done. You're going to do it. Not you, they're going to do it. They're going to be the ones that are going to show themselves. those experiences, and then you're going to focus them on that success. You're going to focus on the long game, how their life's going to be different. You're going to be highlighting how those little incremental changes are going to change their life. And over time, you're going to change their beliefs, their expectations about themselves, and you will change the way they age. You will change their life if you can do those things. Team, if you've got other strategies, if you found any of these things helpful or you've got other strategies you want to share, I'd love for you to drop that in the comments. If you're watching this on Instagram. If you want to learn more about what we're doing in the older adult division, our next cohort of level one is going to start August 14th. Level two, the last cohort completely sold out. So just so that's on your radar. It doesn't come around as often, but that next cohort is going to be October 17th. I'm going to be in Houston, Texas this weekend. We still got some seats. If you're in the area, you don't want to miss it. It's going to be an absolute blast. Then the 22nd of June, we're going to be Charlotte, North Carolina. Then I'll be back in Victor, New York on July 20th. And team, after that, we're going to have an MMOA Summit the following weekend. So that's going to be 727 Denver, Colorado, MMOA Summit. Almost all the faculty is going to descend on Denver, Colorado, and bring you the goods. Team, I hope you have a wonderful Wednesday. We will see you next time.

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

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