Dr. Dale Avers, PT, DPT, FAPTA

Dr. Jimmy McKay PT, DPT: Strengthening without rationale or adequate stimulus is tantamount to malpractice. That one, that one’s just like a rallying cry.

Dr. Dale Avers PT, DPT, FAPTA: I was pretty fired up.

Dr. Jimmy McKay PT, DPT: We love that.

Dr. Dale Avers PT, DPT, FAPTA: Yeah that’s been brought up quite a bit. And I do believe that’s the case. You know I review records for Medicare. That’s one of the things I look for in skilled care: is the dosing appropriate that it requires the skills of a physical therapist. That’s on the positive side. The negative side is that we’re billing for treatments that aren’t going to do any good whatsoever and maybe even do harm.

Dr. Jimmy McKay PT, DPT: Welcome to FOXcast Physical Therapy,  podcast for clinicians made by clinicians. It’s brought to you by FOX Rehabilitation. Find out more at foxrehab.org.

Dr. Jimmy McKay PT, DPT: I’m your host Jimmy McKay. On the program today a professor at the Department of Physical Therapy education at the College of Health Professions, SUNY Upstate Medical University, Dale Avers, on the show. Dale, welcome to the program.

Dr. Dale Avers PT, DPT, FAPTA: Jim it’s great to be here.

Dr. Jimmy McKay PT, DPT: Very excited to get John here we’re going to talk about your white paper from 2009, the Journal of Geriatric Physical Therapy is where the audience can find that-it’s brought up frequently. Your work along with Mary Beth Brown from University of Missouri in Columbia, it’s frequently especially by our founder of our practice Dr. Tim Fox. He loves it-talks about it all the time.

Dr. Dale Avers PT, DPT, FAPTA: Great. I like that.

Dr. Jimmy McKay PT, DPT: But first I actually have to start with that with asking-a little birdie, two little birdies actually told me, that you are a stickler for exercise form. Is that true?

Dr. Dale Avers PT, DPT, FAPTA: Oh yeah I think it is. Yeah. So you know I really believe in intensity. I think intensity for older adults gets an awful lot of bang for your buck. But that does not mean that we tell people to work really hard and walk off and leave them. So I’m a stickler for providing skilled physical therapy which includes form, and understanding what form is which then leads me to say that I’m a stickler for physical therapists really engaging in high intensity exercise themselves, so they get a sense of what good form is.

Dr. Jimmy McKay PT, DPT: Doing It can actually I mean if you say do a sideline leg lift and then you’re instructing someone how they might not be doing it that great. You should get on there and do it yourself right. That’s exactly right. And then you get a sense oh this isn’t as easy as it looks. Yeah yeah you’re one with instead of just telling.

Dr. Jimmy McKay PT, DPT: Or what are some of the exercises that we typically fail to be really really great at instructing form or not not being enough of a stickler?

Dr. Dale Avers PT, DPT, FAPTA: Well I think you brought up a good bench him which is hip abduction. Oh so often I see folks doing it standing which of course is it’s not against gravity so it’s really quite easy exercise and frankly you’re exercising the leg you’re standing on which some folks forget. But then you allow the antier part of the glute to work because of the tightness of the hip flexors and so people don’t go into full abduction with a little bit of posterior movement, which is really where you’re going to emphasize the strength of that glute need. So that’s a big one. Shoulder exercises. You know a lot of older folks have a bit of rounded shoulders and so we don’t consider that we’ve got to really work on stability before we work on mobility. And so that can create a lot of problems. Those are kind of my two my favorite joints.

Dr. Jimmy McKay PT, DPT: Yeah I heard I heard from some students of yours that your therax tests focus a lot on form. Those were little birdies who told me that you were a stickler for the form.

Dr. Dale Avers PT, DPT, FAPTA: That’s funny.

Dr. Jimmy McKay PT, DPT: White paper strength training for the older adult again work by yourself. Mary Beth Brown from University of Missouri published in 2009 journal for geriatric physical therapy a review of the current recommendations for strength training in older adults also to encourage researchers to use published guidelines for appropriate strength stimuli for patients rather than quote usual or traditional care. This thing gets brought up a lot and we love that. The white paper really is right supposed to be a position statement.

Dr. Dale Avers PT, DPT, FAPTA: Yeah you know historically white papers have been used in the industry to present kind of a background for proposal in this case this white paper is really about defining our position about strengthening and because weight papers are usually to talk about a problem that we want to address. This was really instigated because I was pretty frustrated with the undertow saying that I so often saw an exercise prescription for older adults and because there is such a preponderance of exercise prescription evidence there really isn’t any reason not to be doing it. So I thought let’s write a easier kind of one stop shop way for therapists to update their knowledge about exercise.

Dr. Jimmy McKay PT, DPT: Yeah yeah I love that. The clinical significance Pearl that gets use a lot especially within our practice at FOX rehabilitation is strengthening without rationale or adequate stimulus is tantamount to malpractice. That one that one’s just like a rallying cry.

Dr. Dale Avers PT, DPT, FAPTA: I was pretty fired up.

Dr. Jimmy McKay PT, DPT: We love that.

Dr. Dale Avers PT, DPT, FAPTA: Yeah that’s been brought up quite a bit. And I do believe that’s the case. Now I review records for Medicare. That’s one of the things I look for in skilled care is is the dosing appropriate. It requires the skills of a physical therapist that’s on the positive side and negative side is that we’re billing for treatments that are going to do any good whatsoever and maybe even do harm.

Dr. Jimmy McKay PT, DPT: You know you’re using words in the way paper like strength power. You know typically unfortunately don’t get used with older adults for some reason there’s some magical age where you’re no longer supposed to focus on those things. And that’s that’s not OK, especially in our profession.

Dr. Dale Avers PT, DPT, FAPTA: It’s not OK. And Jim I think you’re alluding to some ageism that is unconscious on the part of therapists that might be afraid to apply that kind of that intensity that is going to make a difference. I tell my students you know they’ve all seen the most ridiculous exercise of sitting in a chair with a low ankle weight like a one pound weight around their ankle. They’re kicking out. I talk a lot about specificity and that muscles don’t get stronger in any other way than what we exercise. So what are you trying to achieve with that particular exercise. They all kind of look at me a little blankly and I said I hope that that’s to kick your therapist when he or she does that. I mean it’s like wow what are we asking our patients to do. We don’t expect enough from our older adults and that’s our basic ageism that actually can cause harm to older people. And then the second thing that I asked my students to think about is why, what are you afraid of? And invariably both in continued education and at the entry level people say they are afraid. So what are you afraid of. And eventually they get after this. I’m afraid I’m going to break down which is kind of know isn’t going to happen but at least they’re starting to be honest. And so when we can identify that fear or any fear then we can start using our knowledge and intelligence to overcome that fear and not be kept it by it and even worse allow her patients to be captive by it.

Dr. Jimmy McKay PT, DPT: They’re going to follow our lead. You know if we’re if we’re treating them that way they will start to believe that way.

Dr. Dale Avers PT, DPT, FAPTA: Absolutely right. Plus I would say who else is going to do this physical therapy. So if you don’t do it they’re not going to get the benefit of exercise. How does that set them up for the rest of their lives.

Dr. Jimmy McKay PT, DPT: You know something from that White Paper skeletal muscle requires a workload of approximately 60 percent of maximum available strength to increase strength as one rep max that works for 6 year old 16, 36, or 66 or 96 year old it’s the same.

Dr. Dale Avers PT, DPT, FAPTA: That’s right. Muscle doesn’t change as we get older except that it gets a little weaker and perhaps performs slightly slower rate wise. It’s going to get stronger just the way yours or my muscles get stronger and we’ve got to treat it as such and they need high intensity even more so because they have limited time and resources to give to that program yet to waste that time is just really sad thing.

Dr. Jimmy McKay PT, DPT: And if you’re in a position where you finally have an older adult who needs your skilled care in front of you you’ve gotten all the way to the one yard line for you not to not to push them to sit there one rep max. Oh that’s such a fail on our part. That’s right. That’s right. You probably talked about one rep max the the founder of Crossfit had a great quote. His is “Our understanding is that the needs of Olympic athletes and the needs of our grandparents differ by degree, not kind. One needs functional competence to stay out of the nursing home the other one wants functional dominance to win medals.”

Dr. Dale Avers PT, DPT, FAPTA: That’s exactly right. It’s really of the same ilk. We’re talking about just muscle physiology which there’s just no evidence at all that it’s different as we get older. And I think frankly we retire so that we have time to exercise because it’s so important towards the end of our life for thinking about a 1 rep max know that repetition maximum is such an easy thing to do. No both functionally as well as a single muscle contraction like a biceps or a quad. One of the things that I encourage everyone to do is never tell a patient how many repetitions to do invariably will be under dosing if we do that because it surprises so much. So we just see how many they can do and they start getting six or seven. You know you don’t undertows right rate they’re using keep going.

Dr. Dale Avers PT, DPT, FAPTA: I love to say I love to walk up behind there and say so sir how many do you think you could do. Kind of looks it goes oh maybe 40 or 50 there besides the therapists eye’s are really big. You know how many you’ve got to find out-how many they can do.

Dr. Jimmy McKay PT, DPT: There might be approaching the appropriate weight resistance. In the White Paper it also goes into sets reps frequency reps. You mentioned based on patience effort and form and that’s where we come back to you. Look for that deterioration of form and that’s when you know you’re getting to that 80 percent threshold is that my reading that correctly?

Dr. Dale Avers PT, DPT, FAPTA: Exactly right. And then you document that and say that patient exercised to a loss of form indicating muscle fatigue or failure. Now that’s a skill note. Now I’m now wondering why couldn’t they do 12 if they did 10. Why didn’t they do 12. Because there is no indication about why they quit at that point. Sometimes I think it’s that therapist getting bored or tired. That makes them quit therapists. Are you tired. I E. Why did you quit. Let’s go do some. Sure sure for sure. Ask a patient if they’re tired. I want to see it.

Dr. Jimmy McKay PT, DPT: I’m sure that’s your skilled care right. Being able to walk around with that person has reached that point.

Dr. Dale Avers PT, DPT, FAPTA: That’s right and you document what you’re seeing. Are they sweatign? Are they short of breath or their vitals going up? Are they losing form? Those are the things we’re trained to observe to document and to adjust in our treatment programs.

Dr. Jimmy McKay PT, DPT: Getting rid of manual muscle testing. Talk about that.

Dr. Dale Avers PT, DPT, FAPTA: How about that. I mean it’s ironic because Mary Beth and I are the authors on the Daniels at Worthingham muscle testing book. The fourth edition has just come out. And the reason that I came on to the ninth edition was because I wanted to make muscle testing relevant to physical therapists again. I just felt like we weren’t doing it very well and it wasn’t meaning anything. So I read charts with say lower extremity five out of five generally. So I guess they don’t need exercise that right? I mean it just wow it didn’t make a lot sense. So our book now includes the other strength measures such as functional strength. So so here’s my little spiel on this. Five out of five great especially for lower extremities like quads and gas trucks. There is no way even that quote little old lady unquote that yours or my muscle resistance the resistance we would apply should break their quad or gastric contraction. Those muscles are just too strong in the body and so we can’t accurately grade them. And so a muscle test a manual muscle test is not appropriate for those kind of muscles. I think the doctor is perfect because you can get them on their side you’ve got a long labor arm and that’s one where it’s pretty unusual to see someone be able to withstand a breath test. But even indoors or flexors anger are typically pretty darn strong and a lot of people although I do see that wind getting weaker and older folks. So I think it’s appropriate mental muscle testing on upper extremities that there isn’t a reduced grade. When we take age into consideration that’s just not how it was designed. It really does is it picks up weakness right. It’s not really about strength it’s about weakness. And you’re looking side to side. And so there’s a role for muscle testing for sure but when you’re talking about function it’s a pretty low bar to actually these.

Dr. Jimmy McKay PT, DPT: Paying attention to the individual in front of you is very important.

Dr. Dale Avers PT, DPT, FAPTA: Critical.

Dr. Jimmy McKay PT, DPT: Frequency based on muscle recovery allowing 24 to 48 hours of rest between sessions of the same muscle group sounds like leg day chest day back day arm day. This is you know muscle physiology and exercise prescription 101 no matter who you’re working with or how old they happen to be. Muscle power II. Moving as quickly as possible through the concentric phase of of exercise. A lot of times we don’t think of older adults as needing muscle power but they do yeah.

Dr. Dale Avers PT, DPT, FAPTA: Powers the critical determinant and functional activity that’s been shown over and over again. And yet we lose it almost three times as fast as muscle strength asking somebody you know I advocate one set for untrained individuals which there mostly our older adults but if you want to do two sets do one set that’s power base. So you work on scrength and high intensity and then do power base as high intensity as is possible although probably you’re going to have to drop that down. So moving quickly is so critical especially for balance. So we can’t do enough of that. But let me comment on the kind of the frequency because again a lot of therapists say wow you know how can I do that. I work in a skilled nursing environment or I’m in an inpatient setting or I have to see people either be ID every day. So that’s why we came up with the table that we did where as you said we can do leg leg day on a Monday morning and then do like day again on a Wednesday but on Tuesday we can work abdominals because we forget about the trunks at work. Core and then you can work on posture control and balance in the afternoons or Casper’s civic activities. So you mix the program up which keeps the patient more engaged keeps you more engaged for sure and then doesn’t violate basic exercise physiology principles.

Dr. Jimmy McKay PT, DPT: And getting them to the max they should have a little bit of you know doing onset muscle soreness. You know to me if you want to you want to see that a lot of times we want to avoid anything and Im using air quotes over here “painrelated” with an older adult but you know soreness is something we we know how it happens and delayed onset muscle soreness. injury Is not something we want to go for but there has to be that line. And again that’s what you’re skilled part in the skilled carers.

Dr. Dale Avers PT, DPT, FAPTA: That’s right. That’s right. So I always tell the patient that they are likely to be sore. And I tell them exactly where I want this I’ll point to their clot. I want you to be sore here. I do not want you to be sore at your knee I said and if you’re not sore I’m going to really be pretty disappointed. Oh I really lay that expectation out. And of course you know it’s kind of like the orthodontist remember when you had your braces tightened up and I’m never going back there again. The not for several weeks later and you forget all about it. Well that’s kind of why we schedule people every other day. Right. In the case itself. So they forget about it and I tell them what they need to do that they need to move through it and that any soreness that last more than two days we did it a little bit because we don’t know for sure. Right. These are untrained people that maybe haven’t worked at this intensity quite a while. But I can tell you the reward is just incredible and I can’t tell you Jim how many times after training course I’ll come back home and I’ll tell therapists I want your patients to ask me on Monday morning. Who the hell were you this weekend. Because their plans are so different. And sure enough I get those e-mails going. I cannot believe how under dosing I was patient is so excited about what we’re doing. You know I mean it’s just a great success story it’s a therapist would just give themselves permission to apply what the evidence says you’re going to find. And you should never be bored as a therapist and your patients should never be bored. Yeah it’s a great way of mixing it up and really providing skilled care that’s going to do a lot of good for your patients.

Dr. Jimmy McKay PT, DPT: Good to have you on the show and not long ago a Reader’s Digest article came out laying out and you know you know where I’m going with that. Yes I do. What was your gut reaction to that. Now just for the audience the Reader’s Digest came out with an online article saying 15 exercises you should never do after the age of 50 and not really sure where they picked that 50 number but they laid it out there and a bunch of those physical therapists kind of kind of took issue with all of them.

Dr. Dale Avers PT, DPT, FAPTA: Yes of course we should. So my little known secret is I’m 65. I go to Fit Body boot camp every single day. You have got to be kidding me and doing all of those exercises and more and I feel great. So just taking my personal experience I went kind of a bit ballistic. I have to say. And I thought how ageist is this? And I was really heartened Jim by the groundswell of outrage across professions. But a lot from us and I thought you know this is really terrific that people are starting to get on board with providing evidence based exercise and seeing what older adults actually can do. There’s no limitations. Now clearly high intensity high high intensity cannot be applied indiscriminately. But we do encourage our folks to move through the highest intensity possible because it’s going to make the most good. So if somebody says well I don’t get my muscles really big. I mean that’s kind of like they don’t want to exercise that hard right. I’ll say OK then you’re going to need to spend more time with me because it’s just going to take you longer to get stronger. And then they start seeing dollar signs or time or whatever is their value. And they go oh and they usually come around. So I think that’s the thing is that there’s no one size for every single person you have to consider what their goals are and what their beliefs are. And sometimes you know most times that selling exercise. If people liked exercise they probably would be coming in to see us. So how can we sell it as the best thing since sliced bread.

Dr. Jimmy McKay PT, DPT: Sure the benefit for them. The why in it for them.

Dr. Dale Avers PT, DPT, FAPTA: That’s right yep yep. So we kind of try to push the intensity. But it’s always within that that specificity. And so I’m a big proponent of making sure that you’re engaging that patient with patient related goals really developing therapeutic alliance so that the patient can see why am I doing a lunge.

I haven’t done a lunge in 4 years. Well it’s the first step in getting up off the floor. Oh yeah. But having trouble getting up off the floor. Right. You told me that that’s why we’re doing this. Oh and now they get it. So we’re always going back to what is it that the person wants to do. I also like another strategy is showing so I have them do a 30 second sit to stand. So rather than say oh that’s pretty good. I whip out my Ripley and Jones fitness manual which has such beautiful tables. Ninetieth percentile down in the five year age increments and I’ll sit there and can’t play dumb and go out. Let’s see. How do you say you were 87? Who pay and you did. How many. Eight. OK let’s go. Here it is. All right see what this says. I don’t even say the number and they’ll go thirty fifth percentile. Really. Let me try that again. So again it’s helping them come to that realization of what they need to do rather than I think their best Jim tell. Way too much then ask. We need to ask our patients a lot more than just telling them you know I don’t know that I appreciate a 20 year old telling me what they think is best for me at this point and I’m sure an 80 year old isn’t going to appreciate that from somebody who looks like they’re 12 to that first picture as I tell my students.

Dr. Jimmy McKay PT, DPT: Asking first because the most my background before coming to physical therapy is in communications. So we were thinking about when someone is going to receive a communication best the most important person in a conversation as egotistical as it sounds as always the me it’s always the I, the person receiving that and if you can frame it in such a way they’re going to want to own it.

Dr. Dale Avers PT, DPT, FAPTA: Absolutely. And it takes some time. You know I tell the students you’ve just learned all this great knowledge and I know you want to share it. All good stuff but you gotta do it around the bush. And if I do you’ll get there. It’s just you got to learn how to sell it.

Dr. Jimmy McKay PT, DPT: Yeah I was 150 percent guilty of that. You know my family my clinical rotations my first couple of years out of PT school which is just starting to talk and talk and talk and talk.

Dr. Dale Avers PT, DPT, FAPTA: I can’t wait to tell you all the things that I know they want you to know and that you know listening to a really great therapist you realize they talk like 10 percent as much as I do that will yes. It’s the importance of what they’re saying and how they’re saying it. That’s when you start to realize that but that’s difficult a difficult lesson to learn. You point that out.

Dr. Dale Avers PT, DPT, FAPTA: Yeah and it’s really really important when you’re trying to sell something that’s basically unpopular like a really high intensity exercise program so tight alert and Forge’s I’m sure you’ve had some patience. Remember for the rest of our lives I certainly have that kind of have brought me back to myself and go oh yeah you’re right get a little bossy and strong here.

Dr. Jimmy McKay PT, DPT: Dale last thing we do on the other show is your FOXtail. You ready for that? OK. Why did you decide to work with older adults in your career as a physical therapist? What about that population drew you in?

Dr. Dale Avers PT, DPT, FAPTA: I had four wonderfully-aged grandparents. So I had no bad role models in my life so I didn’t have any negative perceptions about older adults. They just were and I mean here’s a true story. Very humbling. But my first job I decided to go to skilled nursing because I kind of like the autonomy I worked as an ailment for several years before peachy school and of course they made the most money back then. And so I walk in with this giant chip on my shoulder and because I knew they needed a therapist badly and the nursing home administrator looked at me and she goes but do you like older people. I thought to myself What’s that got to do with any true issues. Why did you go home and think about that answer. And I went Wow. So I did and I did and I came back and I worked there for several years then kind of came to the realization that older people really didn’t want to be in a nursing home. So what can I do to keep them out of it. And that’s really where my focus has been. Ever since for the last 40 years so I find older folks to be just like younger folks with a whole lot more wisdom and experience and interesting stories. But some of them are unreal and some of them are not very nice. Some of them are sweet and they’re just older. That’s all. It’s why I like calling them older adults and not any other kind of title or older folks. They’re a group that’s quite appreciated. There’s a group to be taken seriously and to not be put in the ground too early.

Dr. Jimmy McKay PT, DPT: Love that love the way you put that. Dale Avers from the College of Health Professions SUNY Upstate Medical University. White paper strength training for the older adults you can find in the Journal of Geriatric physical therapy from 2009. 2009 we’re still talking about.

Dr. Dale Avers PT, DPT, FAPTA: How about that. Thanks so much Jim it’s been great fun.

Dr. Jimmy McKay PT, DPT: Thanks for listening to FOXcastPT. It’s brought to you by FOX Rehabilitation. FOX clinician’s work hard love their work and get the respect they deserve. Sounds good? Then you’ll love the autonomy to work in your own style and the support you get to achieve excellence, plus freedom and flexibility to have a personal life whether it’s your first day or you’ve been around for a while. Your contribution is acknowledged and rewarded. That’s what makes FOX a success. Happy well-trained clinicians make great health care. Are you a fit for FOX? Find out now at foxrehab.org.