CHAPTER 1 Geriatric Physical Therapy in the 21st Century: Overarching Principles and Approaches to Practice Rita A.Wong,EdD,PT INTRODUCTION and a of p THERAPY working in settings traditionally identified as "geriat- Evidence-Based Practice ledge ahorectotfoiecrndbfd& dvidence-based practice is an approacd patient at least40%of patients across physical therapy clinical settings.Although the fundamental principles of about the care of a patient.Figure 1-1 illustrates these patient management are similar regardless of patient age,there are ons in the mprove practice ometm This chapter starts with a brief discussion of the misleads people into thinking that the scientific evidence is the only factor to be considered when using hegrpnded practice:optima this approach a patient-care de geriabctivity in the use of ouy the role o rcise and physical makingoy one of the three ctal com nt of edible clinical decision ofac chapter con a h is evic rmed practice. mechanisms required o enare aded nding role:it then moves pret and apply this literature in the context of an in the ave expertise to yperform the ap. pret the findings in light of age-related and condition- adults. specific characteristics of the patient,and then to skillfully Copyright2012,2000,1993 by Mosby,Inc.an affiliate of Elsevier Inc
2 Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. C H A P T E R 1 Geriatric Physical Therapy in the 21st Century: Overarching Principles and Approaches to Practice Rita A. Wong, EdD, PT INTRODUCTION This book promotes the reflective, critical, objective, and analytical practice of physical therapy applied to the older adult. All physical therapists, not just those working in settings traditionally identified as “geriatric,” should possess strong foundational knowledge about geriatrics and be able to apply this knowledge to a variety of older adults. Indeed, older adults comprise at least 40% of patients across physical therapy clinical settings.1 Although the fundamental principles of patient management are similar regardless of patient age, there are unique features and considerations in the management of older adults that can greatly improve outcomes. This chapter starts with a brief discussion of the key principles and philosophies upon which the book is grounded: evidence-based practice; optimal aging; the slippery slope of aging; clinical decision making in geriatrics; the role of exercise and physical activity for optimal aging; objectivity in the use of outcome assessment tools; and the importance of patient values and motivation. The chapter continues with a discussion of the geriatric practitioner of the future and mechanisms required to prepare adequate numbers of practitioners for this expanding role; it then moves to the key principles of locating, analyzing, and applying best evidence in the care of older adults. The chapter ends with a discussion of ageism and the impact of ageism on health care services to older adults. KEY PRINCIPLES UNDERLYING CONTEMPORARY GERIATRIC PHYSICAL THERAPY Evidence-Based Practice Evidence-based practice is an approach to clinical decision making about the care of an individual patient that integrates three separate but equally important sources of information in making a clinical decision about the care of a patient. Figure 1-1 illustrates these three information sources: (1) best available scientific evidence, (2) clinical experience and judgment of the practitioner, and (3) patient preferences and motivations.2 The term evidence-based practice sometimes misleads people into thinking that the scientific evidence is the only factor to be considered when using this approach to inform a patient-care decision. Although the scientific literature is an essential and substantive component of credible clinical decision making, it is only one of the three essential components.2,3 An alternative, and perhaps more accurate, label for this approach is evidence-informed practice. The competent geriatric practitioner must have a good grasp of the current scientific literature and be able to interpret and apply this literature in the context of an individual patient situation. This practitioner must also have the clinical expertise to skillfully perform the appropriate tests and measures needed for diagnosis, interpret the findings in light of age-related and conditionspecific characteristics of the patient, and then to skillfully
CHAPTER 1 Geriatric Physical Therapy in the 21st Century Best mel-Smiths anded the oncept of Rowe inclusive term than aging.Brummel-Smith defines optimal aging as "the capacity to function across many domains Patien and on tualization recognizes the impe rtance of timizi functional capacity in older adults regardless of the epenSd presence or absence of a chronic FIGURE 1-1 Key elements of evidence-informed practice. vith ch hea sing lev of disability lea ditioning that further decreases functional ability.Thes communica- declines lead to secondary conditions assoc d wit ns ar to ac new dis tal in reducing the disabling effects of chronic disease processes by promoting restorative and accommodative Optimal Aging changes that stop or reverse the downwar n owing the Rowe and Kahn+first intr aging and usual the pres remind practitioners and researchers that the typical olde Slippery Slope of Aging aging)are quite var mal a style g-re of a of opt as physical activity,nutrition,and stress management resents encourages practitioners to consider er adu sa substantial propor d as that observe wit Th along the v-axis regardless of age can be modified Ten years later,Rowe and Kahns provided further (in either a positive or negative direction)based on s of aging 100 90 80 Fun ability to readily en 50 Function avoid 2 health care practitioners,the reality is that the majorit 10 of older adults do have at least one chronic health condi Failure 100+ Age ctondl associate wit For this large group of individuals.Rowe and Kahn's FIGURE 1-pperspfn depicts model needs to stretch beyond the concept of avoidance of disease and disability
CHAPTER 1 Geriatric Physical Therapy in the 21st Century 3 apply the appropriate interventions to best manage the problem. This is all done with clear and full communication with the patient to assure the goals and preferences of the patient are a central component of the development of a plan of care. Optimal Aging Rowe and Kahn4 first introduced the terms successful and usual aging in the mid-1980s as a mechanism to remind practitioners and researchers that the typical changes in physiological functioning observed in older adults (usual aging) are quite variable and generally represent a combination of unavoidable aging-related changes and modifiable (avoidable) lifestyle factors such as physical activity, nutrition, and stress management. Their perspective encourages practitioners to consider that for many older adults, a substantial proportion of apparent age-related changes in functional ability may be partially reversible with lifestyle modification programs. Ten years later, Rowe and Kahn5 provided further 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 successfully are (1) absence of disease and disability, (2) high cognitive and physical functioning, and (3) active engagement with life. Rowe and Kahn describe a usual aging syndrome as one in which suboptimal lifestyle leads to chronic health problems that affect function and thus the ability to readily engage in family or community activities. Improving healthy lifestyle is encouraged as a means of achieving successful aging. Although helping older adults avoid disease and disease-related disability is a central consideration for all health care practitioners, the reality is that the majority of older adults do have at least one chronic health condition and many, particularly among the very old, live with functional limitations and disabilities associated with the sequela of one or more chronic health conditions. For this large group of individuals, Rowe and Kahn’s model needs to stretch beyond the concept of avoidance of disease and disability. 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 and in spite of one’s medical conditions.”6 This conceptualization recognizes the importance of optimizing functional capacity in older adults regardless of the presence or absence of a chronic health condition. Functional limitations associated with chronic health conditions often lead to a vicious downward cycle with increasing levels of disability leading to greater deconditioning that further decreases functional ability. These declines lead to secondary conditions associated with chronic conditions and, often, to additional new diseases. Physical therapists can be particularly instrumental in reducing the disabling effects of chronic disease processes by promoting restorative and accommodative changes that stop or reverse the vicious downward functional cycle, allowing the individual to achieve optimal aging in the presence of chronic health conditions. Slippery Slope of Aging Closely linked to the concept of optimal aging is the concept of a “slippery slope” of aging (Figure 1-2). The slope, originally proposed by Schwartz,7 represents the general decline in overall physiological ability (that Schwartz expressed as “vigor”) that is observed with increasing age. The curve is arbitrarily plotted by decade on the x-axis so the actual location of any individual along the y-axis—regardless of age—can be modified (in either a positive or negative direction) based on Patient Best available evidence Clinical expertise/judgment Patient preferences and motivations FIGURE 1-1 Key elements of evidence-informed practice. 100 90 80 70 60 50 40 30 20 10 20 100 Vigor (percent) Age Fun Function Frailty Failure FIGURE 1-2 Slippery slope of aging depicts the general decline in overall physiological ability observed with increasing age and its impact on function. (Adapted from Schwartz RS: Sarcopenia and physical performance in old age: introduction. Muscle Nerve Suppl5: S10-S12, 1997.)
4 CHAPTER 1 Geriatric Physical Therapy in the 21st Century lifestyle factors and illness that influence physiological funioning ation that must be brought to bear on a inica er amew s are pre this ally the into model is grounded in the patient-client management can have a large imp model the Guide to Physica Therapist Practice part an em zes th al ro fra erapy nt disablement concept of the World Health Organiza in work, home. leisure activities nationa nto function continues ICF)m ty'are als and of di restrict leisure activities (fun)because of declining physi- substantial emphasis on describing and explaining per- ological capacity.Mov medic environmenta fact rs likely to en- managing Crucial Role of Physical Activity and Exercise in Maximizing Optimal Aging into wo whe ndiv nde concern across age groups th BADl The concept of functional thresholds and the down- ward mo fun to exercise sustainabil o regain physi ical reser appareof rved between t hat physi menrs)and chan ofcare for their older adult patients r as par for a person who is teetering between the thresholds of Exercise may well be the most important tool on and f physical erapist has to positively affect function and “frailt aging.De with its associated functional limitations.Once a per optimal intensity. duration and mode of exercise r moves to a lower functional level (down the curve of the scription,physical therapists often underutilize exercise. optimal negative on the potent to up to a high of tim cise activities may enhance efforts for an up ions may be ciated with such fa ment along the slippery slope.Moreove the furth that lower expe ctations for high levels of function.ack reshold. th of awareness of age-based functional norms hat can b more physi ava P A goa ure ot d h d pe ve role of phy cal the r the of in prevention)that are covered and reimbursed tients/c to und person's insurance benefit.Physica t physiological reserve should every opport nity to apply evi Clinical Decision Making in Geriatric ams that encourage p ositive lifestyle changes and, Physical Therapy thus.maximize optimal aging. eof physical therapy practice sth Objectivity in Use of Outcome Tools ovement and health.Providing a fram rk for clini Older adults be me increasingly dissimilar with increa cal decision making in geriatric physical therapy 1 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
4 CHAPTER 1 Geriatric Physical Therapy in the 21st Century lifestyle factors and illness that influence physiological functioning. Schwartz has embedded functional status thresholds at various points along this slope. Conceptually, these thresholds represent key impact points where small changes in physiological ability can have a large impact on function, participation, and disability. These four distinctive functional levels are descriptively labeled fun, function, frailty, and failure. Fun, the highest level, represents a physiological state that allows unrestricted participation in work, home, and leisure activities. The person who crosses the threshold into function continues to accomplish most work and home activities but may need to modify performance and will substantially selfrestrict leisure activities (fun) because of declining physiological capacity. Moving from function into frailty occurs when managing basic activities of daily living (BADLs; walking, bathing, toileting, eating, etc.) consumes a substantial portion of physiological capacity, with substantial limitations in ability to participate in community activities and requiring outside assistance to accomplish many home or work activities. The final threshold into failure is reached when an individual requires assistance with BADLs as well as instrumental daily activities and may be completely bedridden. The concept of functional thresholds and the downward movement from fun to frailty helps explain the apparent disconnect that is often observed between the extent of change of physiological functions (impairments) and changes in functional status. For example, for a person who is teetering between the thresholds of function and frailty, a relatively small physiological challenge (a bout of influenza or a short hospitalization) is likely to drop them squarely into the level of “frailty,” with its associated functional limitations. Once a person moves to a lower functional level (down the curve of the y-axis) it requires substantial effort to build physiological capacity to move back up to a higher level (back up the y-axis). Lifestyle changes including increased exercise activities may enhance efforts for an upward movement along the slippery slope. Moreover, the further the person is able to move above a key threshold, the more physiological reserve is available for protection from an acute decline in a physiological system. A major role of physical therapy is to maximize the movementrelated physiological ability (vigor) of older adult patients/clients to keep them at their optimal functional level and with highest physiological reserve. Clinical Decision Making in Geriatric Physical Therapy The primary purpose of physical therapy practice is the enhancement of human performance as it pertains to movement and health. Providing a framework for clinical decision making in geriatric physical therapy is particularly important because of the sheer volume of information that must be brought to bear on a clinical decision. Several conceptual frameworks are presented in Chapter 6 and integrated into a model to guide physical therapy clinical decision making in geriatrics. The model is grounded in the patient-client management model of the Guide to Physical Therapist Practice8 and emphasizes the central role of functional movement task analysis in establishing a physical therapy diagnosis and guiding choice of interventions. The enablement– disablement concepts of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) model of disability9 are also incorporated into this model, using ICF language to communicate the process of disablement and placing a substantial emphasis on describing and explaining personal, medical, and environmental factors likely to enable functional ability or increase disability. Crucial Role of Physical Activity and Exercise in Maximizing Optimal Aging Lack of physical activity (sedentary lifestyle) is a major public health concern across age groups. Only 22% of older adults report engaging in regular leisure-time physical activity.10 Sedentary lifestyle increases the rate of age-related functional decline and reduces capacity for exercise sustainability to regain physiological reserve following an injury or illness. It is critical that physical therapists overtly address sedentary behavior as part of the plan of care for their older adult patients. Exercise may well be the most important tool a physical therapist has to positively affect function and increase physical activity toward optimal aging. Despite a well-defined body of evidence to guide decisions about optimal intensity, duration, and mode of exercise prescription, physical therapists often underutilize exercise, with a negative impact on the potential to achieve optimal outcomes in the least amount of time. Underutilization of appropriately constructed exercise prescriptions may be associated with such factors as age biases that lower expectations for high levels of function, lack of awareness of age-based functional norms that can be used to set goals and measure outcomes, and perceived as well as real restrictions imposed by third-party payers regarding number of visits or the types of interventions (e.g., prevention) that are covered and reimbursed under a person’s insurance benefit. Physical therapists should take every opportunity to apply evidence-based recommendations for physical activity and exercise programs that encourage positive lifestyle changes and, thus, maximize optimal aging. Objectivity in Use of Outcome Tools Older adults become increasingly dissimilar with increasing age. A similarly aged person can be frail and reside in a nursing home or be a senior athlete participating in a
CHAPTER 1 Geriatric Physical Therapy in the 21st Century Physical therapists who find geriatrics particularly rewarding and exciting tend to be practitioners who dislike a clinical world of "routine ,and patients with n es,can provide a more c ers enjoy ng creative mance relative to similarly aged oder adu servings highest level of optimal aging and enjoy making common language and as a baseline for measuring prog personal impact on the care of their patients.Navigating tminute wall eent an effective solution in the mids test (175 m). en 01 rovides a more ate des tion than“an older ma who requires mod assistance of two to transfer,walks a walker,and whose strength is WFL. Need for Physical Therapists in Geriatrics tests,appropriate The year 2011 marks a critical date for the Americar he of the baby-boomer generation ued 65 years.This group,born post-World War II,is mucl RED on,both in terms of ON numb er c ing this era( f th 946o1965j Physical therapists working with older adults must ingly although health services rchers have lon be prepared to serve as autonomous primary care casted the substantial impact of this demographi re searchers utors adequate prepar ion has bee tes,in to m et the Although none of these roles is unique to geriatric group of older adults.The 2008 landmark report of ical erapy,what is unique is the remarkable s and the regularity provides physic le ide all le health care workforce (professional,technical,unskilled direct care worker,and family caregiver).These short- them to n L short physica the the apy 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 indepen or a change in tosupport physical thera- us,cogr epressio d size ble eload of physical aspects and provide an additive challenge to the physical therapy practices is the older adult. physical therapist.The physical therapist must be cre- clues about un the c r acc 88 ated acros s,are pa epresents mutually ed-ongoa ptions,the majority of the caseload of the aver physical therapist will soon consist of older adults making the Despite this,physical therapists still tend to think about therapist ethe tha geriatrics only as care pr in a nur sing home or geriatric physical ther- apy,physical therapists must recognize and be ready to vide effective services for the high volume of older ed cation to patient adult patients across all practice settings.Every physica
CHAPTER 1 Geriatric Physical Therapy in the 21st Century 5 triathlon. Dissimilarities cannot be attributed to age alone and can challenge the therapist to set appropriate goals and expectations. Functional markers are useful to avoid inappropriate stereotyping and undershooting of an older adult’s functional potential. Functional tests, especially those with normative values, can provide a more objective and universally understood description of actual performance relative to similarly aged older adults, serving as a common language and as a baseline for measuring progress. For example, describing an 82-year-old gentleman in terms of gait speed (0.65 m/s), 6-minute walk test (175 m), Berg balance test (26/56), and Timed 5-repetition chair rise (0) provides a more accurate description than “an older man who requires mod assistance of two to transfer, walks 75 feet with a walker, and whose strength is WFL.” Reliable, valid, and responsive tests, appropriate for a wide range of abilities, enhance practice and provide valuable information for our patients and referral sources. THE PATIENT-CENTERED PHYSICAL THERAPIST ON THE GERIATRIC TEAM Physical therapists working with older adults must be prepared to serve as autonomous primary care practitioners, and as consultants, educators (patient and community), clinical researchers (contributors and critical assessors), case managers, patient advocates, interdisciplinary team members, and practice managers.11 Although none of these roles is unique to geriatric physical therapy, what is unique is the remarkable variability among older adult patients and the regularity with which the geriatric physical therapist encounters patients with particularly complex needs. Unlike the typical younger individual, older adults are likely to have several complicating comorbid conditions in addition to the condition that has brought them to physical therapy. Patients with similar medical diagnoses often demonstrate great variability in baseline functional status and may be simultaneously dealing with significant psychosocial stresses such as loss of a spouse, loss of an important aspect of independence, or a change in residence. Thus, cognitive issues such as depression, fear, reaction to change, and family issues can compound the physical aspects and provide an additive challenge to the physical therapist. The physical therapist must be creative, pay close attention to functional clues about underlying modifiable or accommodative impairments, and listen carefully to the patient to assure goal setting truly represents mutually agreed-upon goals. In addition, the older patient is likely to be followed by multiple health care providers, thus making the physical therapist a member of a team (whether that team is informally or formally identified). As such, the physical therapist must share information and consult with other team members; recognize signs and symptoms that suggest a need to refer out to other practitioners; coordinate services; provide education to patient and caretaker/family; and advocate for the needs of patients and their families. Physical therapists who find geriatrics particularly rewarding and exciting tend to be practitioners who dislike a clinical world of “routine” patients. These practitioners enjoy being creative and being challenged to guide patients through a complex maze to achieve their highest level of optimal aging; and enjoy making a more personal impact on the care of their patients. Navigating an effective solution in the midst of a complex set of patient issues is professionally affirming and rarely dull or routine. Need for Physical Therapists in Geriatrics The year 2011 marks a critical date for the American population age structure, representing the date when 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 number of children born during this era (1946 to 1965) and increased longevity of those in that cohort. Interestingly, although health services researchers have long forecasted the substantial impact of this demographic shift on the health care system and encouraged coordinated planning efforts, inadequate preparation has been made to assure sufficient numbers of well-prepared health care practitioners to meet the needs of this large group of older adults. The 2008 landmark report of the Institute of Medicine (IOM) Retooling for an Aging America12 provides a compelling argument for wideranging shortages of both formal and informal health care providers for older adults across all levels of the health care workforce (professional, technical, unskilled direct care worker, and family caregiver). These shortages include shortages of physical therapists and physical therapist assistants. The report provides numerous recommendations for enhancing the number of health care practitioners and the depth of preparation of these practitioners. The goal of this textbook is to provide a strong foundation to support physical therapists who work with older adults. A sizeable proportion of the caseload of most physical therapy practices is the older adult. A recent large-scale physical therapist practice analysis1 reported that 40% to 43% of the caseload of physical therapists, aggregated across clinical practice settings, are patients age 66 years or older. Undoubtedly, with very few exceptions, the majority of the caseload of the average physical therapist will soon consist of older adults. Despite this, physical therapists still tend to think about geriatrics only as care provided in a nursing home or, perhaps, in home care. Although these are major and important practice settings for geriatric physical therapy, physical therapists must recognize and be ready to provide effective services for the high volume of older adult patients across all practice settings. Every physical
6 CHAPTER 1 Geriatric Physical Therapy in the 21st Century atricpist should be well grounded n ooidrakin s recommen ions related to were Clinical Expertise in Physical Therapy lifelong learning.Experts sought out mentors and could Clinical 15 of the three ancho EB er for enhanc sion m alt practice and used self-reflection regularly to identif movwdge chnical reasoning,vei strengths and weaknesses in their knowledge or though ou proce thei ongoing se nprovement :1-3.hment from ner(physical therapy student)typically examines each about what he or she could have done differently that dimension as a disc rete entity.As professional develop- ul have allowed the pa ment progresses,the egins to see th Exper actce The apy.The ps a an h ops.Expert practitioners describe these four dimensions ssed from novice to expert.Figure 1-4 illustrates as closely interwoven concepts and explain their rela tionships in terms o vell-articula ophy expre dcs generalis f a decision making with the patient. erts started their careers anticipating specialization in This model for expert-practice professional develop- ment was examined for each of four physical therapy ence as a nev ndradni Clinical Expertise they had for workine with older adults and were called to action by their perceptions that many at-risk older adults were receiving inadequate care.They became Virtue Life sp ach 04 Students Education Novice nal attribute Hunger for knowledo irtue Do the right thing Energy em Phi sophy of practic Competen Maste Teaching Professional development FIGURE 1-3 De FIGURE 1-4 Conceptual model rating the factors From GM G Hack LN rd KF.Expertise in
6 CHAPTER 1 Geriatric Physical Therapy in the 21st Century therapist should be well grounded in the science of geriatrics and gerontology in order to be effective in making evidence-based clinical decisions related to older adults. Clinical Expertise in Physical Therapy Clinical expertise is one of the three anchors to EBP. Jensen and colleagues,13 through a series of well-planned qualitative studies using grounded theory methodology, identified four core dimensions of expert physical therapist practice: knowledge, clinical reasoning, virtue, and movement. These four dimensions provide a theoretical model to examine professional development from novice to expert. As depicted in Figure 1-3, the novice practitioner (physical therapy student) typically examines each dimension as a discrete entity. As professional development progresses, the practitioner begins to see the interrelationships among the dimensions, with recognition of overlap becoming obvious as clinical competence develops. Expert practitioners describe these four dimensions as closely interwoven concepts and explain their relationships in terms of a well-articulated philosophy of practice. The core of the expert physical therapist’s philosophy of practice is patient-centered care that values collaborative decision making with the patient. This model for expert-practice professional development was examined for each of four physical therapy specialty areas (orthopedics, neurology, pediatrics, geriatrics) using board-certified clinical specialists recommended 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 clearly describe the role each mentor had in their development, whether for enhanced decision making, professional responsibilities, personal values, or technical skill development. Experts had a deep knowledge of their specialty practice and used self-reflection regularly to identify strengths and weaknesses in their knowledge or thought processes to guide their ongoing self-improvement. The expert did not “blame the patient” if a treatment did not go as anticipated. Rather, the expert reflected deeply about what he or she could have done differently that would have allowed the patient to succeed. Expert Practice in Geriatric Physical Therapy. The geriatric clinical specialists interviewed by Jensen and colleagues each provided reflections about how he or she progressed from novice to expert. Figure 1-4 illustrates the conceptual model for the development of expertise expressed by geriatric physical therapy experts. In describing their path from new graduate generalist to geriatric clinical specialist, none of the geriatric experts started their careers anticipating specialization in geriatrics. They each sought a generalist practice experience as a new graduate and found themselves gradually gravitating toward the older adult patient as opportunities came their way. They came to recognize the talent they had for working with older adults and were called to action by their perceptions that many at-risk older adults were receiving inadequate care. They became Clinical Expertise Virtue Knowledge Clinical reasoning Movement Virtue Knowledge Clinical reasoning Movement Student Novice Virtue Knowledge Clinical reasoning Movement Competent Virtue Knowledge Clinical reasoning Movement Master Professional development Philosophy of practice FIGURE 1-3 Developing clinical expertise: Moving from novice to expert practice. (From Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in physical therapy practice: applications for practice, teaching, and research. ed 2, Philadelphia, PA, 2007, Saunders Elsevier.) Types and sources of knowledge Mentors Patients Students Education Clinical reasoning Diagnosis and prognosis within disability framework Life span approach Motivation Management of multiple tasks Personal attributes Hunger for knowledge Do the right thing Energy Philosophy of practice Decision making Physicality Community Teaching FIGURE 1-4 Conceptual model illustrating the factors contributing to the development of expertise in geriatric physical therapy. (From Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in physical therapy practice: applications for practice, teaching, and research. ed 2, Philadelphia, PA, 2007, Saunders Elsevier. p. 105.)