Many elderly people develop movement problems that can affect their coordination, balance, mobility and comfort. Movement disorders are often triggered by an injury, illness, operation or disease. Movement dysfunctions can also develop when a person tries to compensate for muscle weakness, chronic pain or impaired sensation.
Movement disorders and dysfunctions can increase a person’s risk, and fear, of falling. It’s estimated that between one third and one half of Americans ages 65 and older fall at least once per year, and fall-related injuries are the leading cause of accidental death among older adults. Falls account for more than 90 percent of all hip fractures among older adults and are responsible for nearly 40 percent of all hospital admissions for seniors.
There is hope, however, for people with movement problems. These conditions can be at least minimized, if sometimes not completely cured, through physical therapy interventions. Physical therapy can also help the frail elderly improve their conditioning and flexibility, build muscle strength, alleviate chronic pain, maintain their independence and stave off disabilities that their weakened state puts them at risk of developing.
To learn more about physical therapy interventions for older adults, Bay Area Summit spoke in September 2008 with Lise McCarthy, PT, MA, GCS. McCarthy is certified by the American Board of Physical Therapy Specialties as a clinical specialist in geriatric physical therapy, and she heads McCarthy’s Interactive Physical Therapy (MIPT), a private fee-for-service and Medicare provider based in San Francisco.
Founded in 2000, MIPT evaluates and treats adults of all ages with a wide variety of medical conditions. McCarthy specializes, however, in working with older adults, including those with cognitive deficits, increased frailty and a high risk of falling. Most of her clients are in their 80s and 90s.
McCarthy’s specialization remains a rarity – there are currently less than 1,000 board-certified geriatric PT specialists in the entire United States. McCarthy has served on the board of the Coalition of Agencies Serving the Elderly (CASE), and she has helped convalescent hospitals, assisted living facilities and other long-term care homes develop or improve physical activity and restorative nursing care programs.
Bay Area Summit (BAS): What sets the geriatric PT specialization apart from other types of physical therapy?
Lise McCarthy (LM): The main difference is that geriatric physical therapists have met certain standards set forth by the American Board of Physical Therapy Specialties, which involve submitting evidence demonstrating completion of at least 2000 hours of direct clinical practice in geriatrics and passing a rigorous all-day written examination to demonstrate advanced knowledge in the specialty field of geriatric physical therapy. Just like physicians who specialize in different areas, physical therapists can specialize in pediatrics, sports medicine, neurology, orthopedics and, in my case, geriatrics. It makes sense that there are healthcare professionals who have advanced skills and knowledge to better serve those people with more specialized needs. For example, I often work with people who have balance problems, chronic pain, or extensive debility after an illness. Many of them have dementia or impaired cognition, and I think the potential for improved quality of life in this population is generally not very well appreciated, but I have had success in working with them. I frequently hear from families that they are glad they found me.
BAS: What issues do geriatric PT interventions generally focus on?
LM: I start with a detailed history and examination, which can include performing tests or screenings. Among the range of issues I look at are mobility limitations, fall prevention, home safety, and functional capacity. I also look at what medications a person is taking and identify those meds which might be negatively contributing to a patient’s problem. In some cases I refer patients back to their physician for further medical consideration or because I want further medical diagnostic work done. I look at the kind of support network the person has in place, because that makes a huge difference to the success of their treatment, progress and recovery. When appropriate, I may contact other parties involved in the person’s overall care. I also look at their equipment needs. Do they have a walker that is well-matched to their specific walking needs and abilities? When a person has a chronic condition, the focus of my physical therapy intervention may be on developing a plan to maximize and maintain functional status or prevent functional decline, also determining the person’s need for assistive equipment, and training the person and his or her family and care providers about safety and appropriate exercises.
BAS: Where do you see your clients?
LM: I visit most clients in their homes. Some are in assisted living communities, nursing homes, board and care homes or other senior residential communities. Providing these services at home makes things a lot easier for older and frail adults who may have difficulty going out into their community for these services. I also meet some clients at swimming pools for aquatic therapy. I don’t think there are many PTs in private practice who see people in their homes. Most in-home physical therapy services are provided by home health agencies, but therapy is also provided in outpatient clinics and hospital settings.
BAS: How do you identify and address problems that can increase a person’s fall risk?
LM: It’s very important to conduct a fall risk assessment when an older person has fallen or is concerned about falling. The healthcare community is starting to look more closely at fall prevention strategies to reduce the high number of fractures and deaths that can occur from falling. A fall risk assessment includes a look at the person’s home environment and what can be done to make it safer. I also look at functional capacity, postural control, strength, joint movements, balance reactions, vital sign changes with exercise and position changes, and I look for compensatory movement patterns that could affect the person’s balance. I also look at any medications the person is taking and how these might contribute to fall risk. After the assessment is done, I make recommendations on ways to reduce fall risk.
BAS: At what stage do you usually get involved with a client, and how are clients referred?
LM: Most of the people who come to me have gotten to a place where they have been through the rehab process, but they are still experiencing difficulty moving and they want to take a look at what other therapy options may be available. I’m kind of a “second opinion” person. I get a lot of complicated cases, people who are looking for a clinician who specializes in geriatric issues, who can take the time to take a very close look at them and their entire presentation. Many of my patient referrals come from physicians. They also come through care managers, conservators, social workers and other healthcare professionals, and from assisted living and other senior residential communities. There are actually more referrals than I can accept because I’m a solo practitioner and there is such a big and growing demand for geriatric PT specialists.
BAS: What are some of the techniques you use to help clients achieve therapy goals?
LM: A lot of what I do initially is to talk to my patients and their families and caregivers, listen carefully to what they all say. I don’t want to repeat therapies that have already been tried unsuccessfully and I want to understand what their real issues are. I also screen them from head to toe and obtain a thorough history. I am most effective when I understands people’s issues and what they want to achieve, and when people understand and agree with the goals of the treatment and when the therapy is doable. The trick is to find something the people will accept and consistently follow through with. The process may involve setting up a paced exercise program, or looking at what equipment is or isn’t working for the person and how they use it. The program I develop also may focus on a part of the body that hasn’t been focused on before by other therapists or doctors. I focus a lot on teaching and educating my patients about what they need to do to reach their goals, and getting them to see different ways of looking at things and to accept realistic goals. It takes patience and understanding on both sides.
BAS: How do you generally define success in working with frail elderly clients?
LM: My number one goal is to have really good communication between me, my patients and their families and caregivers, and their physicians. I like helping people live more safely and more comfortably at home for as long as possible. One of the best things I can do is help people reach what I call a “lightbulb moment,” when they can really understand what their options are from here and why I have made certain recommendations. Rarely is physical therapy not successful in some measured way, but there are times when a person may need to turn to other service providers to address residual issues. In these cases, at least my patients come away feeling understood and in charge and with the sense that they have tried the PT path fully. This is an important step on their journey.
BAS: Do you have any success stories you’d like to share?
LM: I like helping people walk again. I’ve had people come to me who have not walked for months or in some cases years. Some have been told they would never walk again. I have been able to provide them with an appropriately paced exercise program, and information about how to succeed in meeting their particular goals and about equipment that allows them to take the necessary steps and learn to walk again. One of my clients was told he’d never walk again. I helped him obtain a shoe lift and the right walker that matched his specific needs. He was motivated and eventually became strong enough to walk from his apartment to the YMCA several blocks away to swim. I’ve also been successful in reducing some types of pain for patients. I’ve had good success with people with cognitive deficits or dementia, and getting them and their families and caregivers to work together on a progressive or maintenance exercise program to maximize their mobility skills. It takes time and motivation, the right equipment, the right approach. This has been a recurrent theme in my practice.
For information about McCarthy’s Interactive Physical Therapy (MIPT), see http://www.mipt.us. Information about the American Physical Therapy Association’s geriatric specialist certification program is available at http://www.apta.org. An article describing the potential benefits of geriatric physical therapy is available at http://preventdisease.com/news/articles/physical_therapy_elderly_staves_disability.shtml. Lise McCarthy can be reached by email at Lise@mipt.us or by phone at (415) 665-4953. McCarthy is currently not contracted with any health insurance company other than Medicare, and information about her professional fee schedule may be obtained by calling MIPT.
Disclaimer: The views and opinions expressed by the subject of this interview are not necessarily those of Bay Area Summit or its sponsors.
(This article originally appeared in the Fall 2008 issue of Bay Area Summit)