The Art of Aging Gracefully: A Conversation with Geriatric Physiotherapist Mercedes Fernandez

Parker Condit: 0:00

Hi everyone, welcome to Exploring Health Macro to Micro. I'm your host, Parker Condit. In the show I interview health and wellness experts and by the end of each episode you'll have concrete, tangible advice that you can start implementing today to start living a healthier life, either for yourself or for your loved ones. And that's the macro side of the show. The macro side of the show is discussing and having conversations around larger systemic issues that are contributing to health outcomes, at least here in the US. An example of that would be discussing health disparities, and not just the fact that health disparities exist, but trying to dig into something like a lack of cultural understanding or lack of cultural awareness between a clinician and a patient and how that can influence outcomes. And that's actually something we end up discussing on today's show. My guest today is Mercedes Fernandez. Mercedes is the founder of Mouvement and she's a geriatric physiotherapist. We discuss a lot on today's show, but I'd say the main theme is discussing aging populations and aging parents, because that's largely what she does professionally working with the geriatric population on their mobility and their strength and helping them age gracefully. Some of the things we discuss are how to be a caregiver in the very complicated US healthcare system, strengthen mobility routines for people who are living at home, have limited access to gym equipment, and what you can do just inside your own home, how to properly set up mobility aids like walkers and canes. What it means to age gracefully and how there are cultural differences to that. And then we also discuss how to have better conversations around social determinants of health and some of these other factors that probably aren't getting enough attention in today's world. So I really hope you enjoy my conversation with Mercedes Fernandez. Mercedes, thanks so much for being here. Can you share a little bit how your upbringing sort of led you to your current career path and what you're doing professionally?

Mercedes Fernandez: 2:01

Absolutely. It's a pleasure to be here. I don't know how to summarize it in the best terms, but my grandfather basically raised me. My parents were very busy working and so I was very close to him and he was blind in his left eye, so a little discolored, but for me as an infant and a young child it was absolutely normalized. So we grew up, I ended up taking care of him as he got older, and so this instant bond that I had with him really led me to gravity. I think naturally, organically, to working with older adult population and individuals with disabilities, because for me it's been so natural. I wasn't very shy about it. And yeah, I've created three companies about around older adults walking, fitness, exercise and now, with this current company, more consulting.

Parker Condit: 3:01

Okay, so can you describe a little bit about what you're doing, just to give people some context.

Mercedes Fernandez: 3:05

Yes, of course. So it's movement geriatric physiotherapy, and what my mission is here is to not only help individuals stay mobile, but to educate and inform and advocate for better mobility. So a lot of the cases that I work with is that mobility and mobility aids so canes, walkers and crutches are really big part of mobility as the age, and so they often are set up incorrectly and no one really knows about it. So people start to use them and it ends up leading to a lot of pain, a lot of aches, some falls, and so essentially with this iteration of movement is that I can help someone identify what those mobility aids are, where they're incorrectly set up, excuse me and then how to set them up properly, how to walk with them, what not to do, and then teach anyone, if there's a caregiver involved, what to look for as well.

Parker Condit: 4:08

Yeah, we're definitely gonna dive more into the caregiver aspect as we go. But this is why I love podcasting, because, like, I've worked in fitness and healthcare before but never have I thought about the implications of incorrect mobility aid setup. But, like, clearly it's gonna be a really important topic and we're gonna dig into the specifics as we go. But I wanna say a little bit more on the macro level right now. To you, what does it mean to age gracefully? Because there's some different considerations culturally based on where you are. But to you let's start there what does it mean to age gracefully?

Mercedes Fernandez: 4:41

Yes, it's such a. It's a very subjective question, I think when you think about ageing gracefully, something that for me, what is graceful might not be graceful for you. And so ageing gracefully, from me personally, is finding those rituals, finding those habits that make you feel comfortable in your body, makes you feel comfortable in your skin, and to age gracefully is to have that support as well. So again, going back to I've thought about this of, again, it's a very subjective question and I think that the counter question is what is positively aging and we break it down is essentially they're labels, right? It's almost like a conundrum or a paradox, because we've been conditioned in society that ageing is actually not graceful. Ageing is opposite of positive, I guess, which is for me. Again, I came up in this world of a very natural outlook of seeing an older adult, of seeing the complexities of ageing. So when you age gracefully, you are in a situation when you feel comfortable with your life. It's a very I think it's very convoluted. It can be, but again, it's subjective and it goes against the grain of what society has taught us what ageing should be like, what ageing is and the way that we view our own bodies.

Parker Condit: 6:22

So it kind of sounds like you have more of a positive spin on ageing. So it kind of leads me to the question of what's your opinion on death, or your thoughts on death, because I think your relationship with death is probably gonna be very influential on how you age or how somebody else ages.

Mercedes Fernandez: 6:42

Yes, that's an excellent question, and I think that here's the thing around death and it again coincides with ageing is that we are, I would say there is a universal fear around death, death, ageing, dying, but there is almost a sense of it's hard for me to say because I haven't approached this part of my life. I think something that I hit a lot is that, oh, you're so young and you don't understand, but I myself I have, yes, I am young, but it is again a subjective experience, so I don't feel the same as I was 10 years ago when I was in my 20s. And so, going back to the death question is how can we shape a more positive outlook of death when it comes to ageing? And I think maybe, perhaps the older we are, the more closer we get to a universal acceptance that that is coming. The theme around death is like. The theme around ageing is like. People are like oh, ageing is scary. Oh, unfortunately, I've in my time in studies and clinical work, a lot of people are like, oh, you work with elderly. They're kind of it is a terrible way to say it because they're like scared of them or they're like pushed off, excuse me, turned off. People are like, oh, yes, kids, and so they almost treat this population much like death, of like oh, they're a little like, oh, kind of scary, they're eerie If they didn't have any exposure to a grandparent or older person. I think that that's kind of where I was going with the whole death scenario. People are like mm death, don't want to talk about it, shun, shun shun. But I think, really embracing the aspect of when you are closer to that, or when you are closer to an older adult, you kind of come to this realization of, well, we are all actually going to die. And how do we find that universal acceptance?

Parker Condit: 8:57

That's a great point and kind of the circumstance that you were describing, sort of that fear or maybe resistance to death. I'm not sure if that's more an American thing, but can you speak to any like cultural differences? Because it does feel like right. America is such a capitalistic culture where once somebody's retired and they're old, they have less to contribute from a capitalistic standpoint in society and it feels like they're just sort of discarded in the world and I think there's a large sense of like lack of purpose for a lot of these people who are older and they feel like kind of discarded by society. But I'm curious if you've noticed, currently living in Europe and then given your background, there's any cultural differences you can speak to.

Mercedes Fernandez: 9:42

Absolutely. I think that my experience will, being from the US, being California, and so American, Mexican American I've seen, and being in the healthcare system there as a health practitioner, professional, and then culturally, so professionally and personally Speaking, there is a complete difference. Absolutely Because culturally, at least for the Mexican culture, I can speak on the Hispanic culture we actually really do review our elders, so I can imagine in a perspective of a like I'll use my grandfather for an example. He was aging. I knew him all the time as an older, as an abuelo right, and so I never saw him in his youth, I never really, but I respected him, I loved him and so did all my other family members. So for that aspect there is a big cultural difference. Because, working in assisted living centers, the predominant demographic is white, Caucasian, so there's already a disparity there, which I think is pretty well known in America, of different cultures. However, I think that might be changing on the younger generations now who are working a lot more, so the wife and the father are both working, they have kids, so they're not able to take care of their parents like they would in Mexico or now. So that demographic might be changing. I haven't really been working in those retirement communities in a while to speak on that, but especially here in Europe, in a completely different continent. First of all, the healthcare is absolutely different in like the best way possible and secondly, the thing that I've noticed the most is that the elderly here, the older adults here, are not what we consider elderly in the States, because they're actually active. I'm currently in Belgium, so it's a very big bike community and I see daily individuals who are maybe 70 and up still riding their bikes, going to the cafe, socializing. They're by themselves. We live next to a hair salon. There's older adults in there getting their hair done, so there's a lot of mobility here. There's people, they're in and out. They're not really home, they're not sitting at home, Whereas in America we're more car forward. So we have a lot of our elders really staying at home or they're living in a residential community where their kids maybe are near, they're far it. Just there is really a big, there's a gap there.

Parker Condit: 12:36

Yeah, I think you just highlighted a few like the larger systemic issues that a lot of people probably don't think about if you just kind of grow up here and just don't spend a lot of time thinking about it. But the fact that we are such a car-centric culture, like most cities, aren't made for people to continue to be active, especially as you age. Where in Europe it's totally different, right, everything is built around walking, mobility, cycling, as you mentioned, and then any of the people that I know who are kind of aging and are still incredibly active. They just never stopped, they just never got a point in. They've just always been skiing and hiking and just actively walking, like my grandma. She's turning 100 in January, so probably around the time this will be out. But she's broken her hip twice, just rehabbed it and, like you know, breaking your hip post-65, huge, huge deal, rehabbed it very successfully and just for so many years, like almost my lifetime since then has just always been like, oh, I just walked down the hallways at assistive living facilities. It's just staying active and it's just not losing it. But it's very different. That's not really our culture here, at least in the US.

Mercedes Fernandez: 13:52

Absolutely. That's incredible. I just have to jump in there for your grandmother Like two hip replacements, like again to your point. She didn't stop and I firmly believe you're in fitness as well. The famous adage if you don't use it, you lose it, and I can a thousand percent I agree with that.

Parker Condit: 14:17

But like it kind of like. That's what troubles me, though, because, like I said, like it's not just an issue for the aging populations here, it's also like that the same environment, the same system that we're all sort of operating in here is not built to get people moving Right. It's all very spread out. I do want to kind of go back to the idea that I'm wondering if, like the availability of mobility in this country as far as like the ability to move to different cities, families being more dispersed here, whether that plays a difference. Have you noticed anything like that where the fact that people can move around more easily and they can be across the country that it sort of leaves aging parents more isolated or more in the care of sort of these assisted living facilities, where it's not necessarily family that's helping them through that process?

Mercedes Fernandez: 15:06

Absolutely. I think that that's kind of the concept of what I had was leading to a little bit ago. Was that because this generation, my generation and perhaps the generation above me I'm in my 30s, to give the listeners an idea of what I'm talking about is that because we have expanded into different roles before the older generations have, we do have that mobility? So, yes, I agree with you that because we have the capacity to live in New York and then a parent are still in San Diego, there is that the gap, I think. For, on top of that, the challenge there is how do we make sure mom and dad are safe? How do we ensure that they're actually getting house care, they're being taken care of? Where do we find that care? Because, on top of that, you have your family and then a lot of, I would say, in my experience personally and professionally, I do see it often that they'll be in their own family world and then a parent will get sick, a parent will have an accident, and then they're like oh, I didn't plan for this, I actually don't know how I'm going to take care of mom, who has a broken hip, who is across the country, and do I slide back, or I take the kids. Who's going to watch them? You know, all of these different movie factors into something that people really don't.

Parker Condit: 16:32

We just we don't plan for it, so yeah, so that that sideways nicely into sort of patient advocacy and caregivers. But I do want to first apologize that we're using the word mobility in slightly different context so far, so for anyone listening we'll try to clean that up. But kind of moving to the point of the fact that, like the US, healthcare system is so difficult to navigate, do you have any tips for people that do have aging parents, that are kind of acting as that caregiver for their aging parents or just anyone that they're close with? It's so much work and you need it feels like you need to be very well versed in how things work here to really be a proper advocate for for a family member or friend.

Mercedes Fernandez: 17:17

Yes, definitely. I think that the first thing that comes to my mind is anyone who is listening, who might be in that situation already is to just be patient, have grace for yourself, because the only way out is through. Essentially, I can't say that, even though I was in the health field, when I was taking care of my grandfather, going in and out of the hospital, there was a lot of things that I didn't know until after the fact, and then at that point he had passed away. It was too late. So I had a lot of remorse and I and it's a very common experience, but I think that you really have to learn through it. In, every situation is different, because you know, a stroke versus a surgery versus a fall or sickness, like all of those, are different aspects of the medical system as well, so they'll have different forms, so have different post acute care, and so I think that the main thing is just ask questions, because a lot of the time there is a power imbalance in the healthcare system, and so the patient or the caregiver will. You know, I think that the culture has been like the doctor is like God, essentially, and so what the doctor says goes, and a lot of the older generation. They really are ingrained in that, in that belief. So they will. They will absolutely listen to the doctor no matter what. But the times have have changed and so I really do. You know, tell caregivers you just you have to ask questions because the doctor might be right, but there also might be some aspects where he's not telling you, he or she is not telling you the truth, or there's like a little thing that you can tweak and you can get. You can get more PT sessions. You don't have to go to post acute care, you can do home health. Hospice can be this, this or that, so they're overwhelmed. Clinicians are completely overwhelmed. They don't have time to sit there and talk to every single patient, especially a grieving caregiver who is in distress. So you know they have no time, so they give it away, excuse me, they give a fast tip and so and it's not their fault, right, that's just how the US medical system is. But there's usually a case manager that is assigned underneath that doctor and that's the person that they need to be talking to as well.

Parker Condit: 19:47

So let's assume we're talking about some sort of hospital visit or some sort of event that ends somebody in lands somebody in the hospital, can you like? Is that case manager? Are they going to be physically in the hospital or are they probably going to be offsite and they're going to reach out to the caregiver afterwards? Or is it somebody you can go and physically talk to and really start to build a relationship with? Is there going to be the person that helps you navigate everything and like post-acute care, like the discharge system is not very good in the US that's why we're so many readmissions, so can you kind of talk us through if that is the case? If it is in the hospital, who should you go see? Is it somebody you can go see?

Mercedes Fernandez: 20:28

Yes, so the case, the case manager, if it's in the hospital. The case manager and I might be wrong on this and be completely honest, but some of my experiences are usually also the social worker. So either they're the social worker, the case manager in one, or there's two of them. The social worker will be the person that will follow the patient out of the hospital into post-acute care and their part of social services. So they are in charge of making sure that that patient is getting out of the care in the hospital, out of the hospital, they're not being abused, they're not being taken advantage of, they're actually getting their home health care, et cetera. In the hospital is a case manager and they're in charge of the same thing, essentially to say you know, this is the discharge, this is where they're going, et cetera, et cetera. Again, I think that they're also very limited. Unfortunately, they probably have 50 patients to one case manager in one level of the hospital. So, but nevertheless, I would narrow it there, because the nurses as well are not the people to be talking to. They're also overloaded. The doctors are not there, they're overloaded. So finding that case manager.

Parker Condit: 21:50

Okay, I don't want to keep harping on it, but again these are just coming back to like the big systemic issues that we're dealing with in this country. Understaffing Hospitals are so weird. Some of them are doing great and they need to dump a bunch of money into their facilities just so they can maintain their nonprofits, that is. Other ones are just more rural hospitals or just they're wiped out from COVID and not being able to do any elective, elective surgeries for the past few years. Yeah, Hospitals are not in good shape, but this is largely a systemic issue, Not the nurses, not the doctors. They could probably speak out about it a little bit more, but that does seem to be happening, but this is largely not their fault. Are there questions to ask? I guess are there questions to ask to see if your family member, friend, whoever you're being a caregiver for, or they're being taken advantage of. Are there any obvious signs of that that you can point out?

Mercedes Fernandez: 22:47

Yes, I think that some of the most obvious is they'll usually say you only have this much based on your insurance. We'll use physical therapy or occupational therapy, for example. There's typically a limit. Again, it goes back to what you were saying it's all systemic, it's funding, it's resources, all these things, but for the most part, again, it's all tied together where the patient and the caregiver are not really given all the options because there's just not enough time, there's not enough resources to sit there, and it goes through all the options. So, asking the questions and if something doesn't set right, it doesn't sound, it doesn't feel right. I'm really just trusting your intuition, the example being okay, you're only assigned 10 occupational therapy sessions within a two-month period. Typically 10 sessions, as you know, for fitness is not enough for rehab, especially when you're over the age of 65, 70, your body's feeling a lot slower. But most people don't ask and they're like okay, well, I guess I only have 10 sessions, and then they lose their strength, they don't finish their exercises and then they fall again and then the cycle repeats. What people don't know here is that you can actually request your insurance and the occupational therapy. Usually home health will request more sessions and you will get them because they need them. The insurance knows you don't heal in 10 sessions, so I think that's one of the biggest places where people get taken advantage of. Often is that because they think they were only told you only get this amount, therefore they can't get any more because they're not asking. So I would just that's an example.

Parker Condit: 24:55

I think that's something that's great for people to have in their back pocket, because why, if you were told you have 10 sessions, why would you know to ask, can I get more? And that they're probably going to grant it, but they're not going to offer it up?

Mercedes Fernandez: 25:08

Exactly, yeah. And then I think it ties to the whole systemic thing is that it's all money. Me being in the, a previous company that I built, was trying to partner with healthcare and what I realized the most is that there's so much red tape and it's all about it's all about money. So if you don't have the capital and it's not even just that you have to find your way in, but I'm sure someone's going to come after me for this. But the thing is it's regulated. And the thing I've learned the most being in Europe is that the United States healthcare insurance the insurances are private, so everything is to the advantage and the profit for each individual insurance, aside from federal Medicare and Medi-Cal. On top of that, you still have to pay for benefits. So all of these insurance companies are really just trying to get your business, like Apple Wood versus Microsoft from Google. It's like ads. They're just all competing and then, once they get you in, you're like, okay, great, you cost us a lot of money, you're paying us X amount, but we're not going to make, we're not going to let you use all of your services, because we really need to keep that in our pool. So that would be next year funding. So it's all the cyclical cycle and like that's our frustrates me the most is because most people will be like oh well, is it covered by Medicare? Is your service covered by Kaiser? I don't want to pay for it because I already paid so much for insurance and you're like I wish I could say yes, but right now, as a small little company, a small business I actually cannot get in to these healthcare to help the population that needs to help the most.

Parker Condit: 26:59

So yeah, yeah, it's a very hard problem to solve but yeah, it does all come down to money. And then you were mentioning everything's private except for the government programs. But even the government programs, as you probably know, now more than half of Medicare is on Medicare Advantage, which is actually administered by private companies. It's the same. Ed knows United's blues that everyone else knows. So even though it's like our tax dollars are largely funding, they're largely subsidizing these insurance companies. Yeah, it's wildly frustrating.

Mercedes Fernandez: 27:33

It's just when you find out you're like the world's kind of coming close a little bit.

Parker Condit: 27:39

Yeah, we'll probably end up circling back to this at some point because it's impossible to talk about any of this stuff without kind of coming back to these larger issues. But I'd love to kind of go on to like talking about mobility and strength training now, like if we can just dive into any sort of specifics. I think the easiest place to start is just describing the people that you work with most often, because they're probably going to be very similar symptoms for this particular population, and then we can kind of just go into some of the nuances of mobility aids, best strength training protocols, things like that. So can you just describe who you're generally working with?

Mercedes Fernandez: 28:13

Yes, I generally work with older adults above the age of 70. Some are in, some have mobility function, Others are wheelchair bound or yeah, I would say more maybe not wheelchair bound but less mobility capabilities. So I work with people who have had a history of exercise, but I would say that this whole fit or our realm of fitness culture is also been relatively newer because the population that I work with was in the labor market. So a lot of them were either in the war or worked on railroads or construction. Those are pretty common occupations for my clients and I would say that's pretty much the big gist.

Parker Condit: 29:13

So what are you working on with them mostly? Is it like regaining confidence, walking, is it lower back issues? Is it shoulders? Is it hips? Is a little bit of everything?

Mercedes Fernandez: 29:22

Arthritis yes, arthritis is a really big one. The biggest thing that I work with the most is pain, back pain and it usually always comes from tightness. Again, it just depends on what they're, if they're using a mobility aid or how they're walking. One of the biggest things that I see the most is that the older adult will usually let they love their shoes. So one of the biggest precursors of lower back pain and just achiness in general, but lower back pain predominantly is worn out shoes. So the shoe is dented in, there's no sole and they will often drag without knowing that. All of this, the spongy shoes the thing that drives me the most nuts about the orthotic companies and they market towards the older adult community is the sponginess and so soft shoes anything with you know I'm sure you know I'm talking about like Nike's even Nike's are just this sponginess is really not good for the body, especially as you age, because it's just the biomechanics of it is compromising and actually making you hurt more than it's supposed to support you. So they did excellent marketing.

Parker Condit: 30:48

Yeah, no, it's really frustrating, Like I'm trying to hook us. It's like. It's like these shoe companies are just competing now to see who can make the thickest, foamiest soul Like you look at hocus shoes and they're like that thick of just foam. So I'm fairly familiar with like why that's not great. But can you speak to proprioception, like gradually loading impact on the body, and like why why you want better shoes and not just it makes sense, why you would market, be like, oh, it's soft, it'll feel better, like it's a very easy linear relationship, but can you explain why that's not always the case?

Mercedes Fernandez: 31:28

Yes, I, it's been a while since I've used my kinesiology term, so I'll do my best. But in you know, in the in the easiest summary is that we really actually need that impact. We need that hard. It's not extra hard impact, we need a little bit of this, and I'm doing this so people can see. But we need this heel, or impact in our heels, so that energy transfers up towards our or our leg and our skeletal system and all the muscles then work together to stabilize and help us walk. So the softer, the softer the surface, the more we're actually not getting that, or the impact is absorbed into this, the softness, and so then you know the, your foot and everything starts to mush everywhere, and again that it for me, the way I understand it is, the transfer is not going directly up the leg, as it's supposed to, and then your hip and everything else, and it's all attached to the spine. The human body is so amazing, is it's going to? You're leaning one way or you're not actually being flat, and so all of the biomechanics are just a little off and with that soft squishiness over time, your body really isn't getting that. I can't remember what the actual force term is, but you're not really getting that the stability and the impact, essentially the upload or on the Okay.

Parker Condit: 33:05

Yeah, the Like the big thing that it was always for me you can reference like some running studies. So they've used like force plate treadmills with people with like big cushy shoes on and then people wearing like minimalist barefoot and I'm not suggesting that people go from a big cushy shoe to a minimalist. You want to step things down and you want to work with somebody who's kind of done that before and can guide you through that transition. But the people who are wearing like big cushy shoes, their impact is significantly more when you're running out of force plate treadmill because like they, so they can just drive way more force into the ground, which is not ideal Because you can be you can just be lazier with your mechanics. But the other big thing is like proper reception, Like are you actually feeling the ground anymore? And when you have this like a pillow under your foot, you're going to have a very little sensitivity to like oh, am I always living on the outside of my foot? Do I? Do I toe off properly, Do I? Get the ball of my foot down, so you lose the sensitivity and, like, the skill of feeling your foot on the ground, which is weird to describe. But falling is a huge issue and having that proper reception is is very important.

Mercedes Fernandez: 34:14

Absolutely, absolutely.

Parker Condit: 34:16

How do you differentiate mobility and flexibility, because mobility has become, within the fitness world, a very popular term over the past, like 10 years. Do you have a definition for people to differentiate between flexibility and mobility?

Mercedes Fernandez: 34:28

Yes, I think the easiest way to define or differentiate between the two is that flexibility is that overall ability to, to reach and to stretch I know it just sounds so simple and like a little bit layman, but but it is and mobility is that the general movement. You know what is the ability to just raise your hand, to stand up straight, to bend over and tie your shoe. That, essentially, is mobility, whereas flexibility is well, can I actually touch my toes? How? You know what's the ability of my muscles to stretch? And I don't think that. I think that the misconception to is like oh well, flexibility means I'm like a yogi and I can, you know, touch my toes to my head backwards. So there is like it's a spectrum, but I think flexibility is are my muscles tight versus very contracted? And then mobility is a general sense of can I even walk to the bathroom and back to bed?

Parker Condit: 35:37

Yes, I guess you're describing as mobility is more like the life application of kind of the combination of strength and flexibility. Yes and probably pro perception to do you have any other any like at home things that people can do? If they're listening to this or they they're a caregiver for an aging parent and they're like they're not going to go to a gym, they can't go to a gym. Is there stuff people can do at home, just like help maintain muscle mass and maintain strength if they're worried about an aging parent who is possibly sedentary?

Mercedes Fernandez: 36:12

Yes, this is, this is like my bread and butter. I personally I don't go to the gym myself because I work. I do everything at home and I think it's pretty awesome. I think that COVID really gave a lot of people that a little bit of an insight to what it's like to be an older adult. I also lived with my grandfather so I understood I'd be like I witnessed this day to day. But one of my favorite things is so simple. We have tools around this. All the time People can do balance exercises with the kitchen counter. We are lifting one leg, trying to balance on one leg, closing one eye, turning your head. You mentioned proprioception a lot, so you know proprioception is really all about understanding your awareness and space. So you know. So that's for balance. It's very simple. You can just even hold on to a wall, the bed, something that's fixed and not movable, so you definitely don't want anything that's going to help you fall. So that's one. Balance is easy. First, train Something that I really enjoy is a sit to stands in a chair. So how often do we sit and then stand right if it's like a absolute, necessary function that we do? And I think that something that I've seen throughout my career is in, and it's really probably the most. It's the hardest and slightly depressing is that when you don't have the straight to stand anymore, you know the despair that comes with these individuals who are like I can only sit now and that really is. That is preventable. You know, it can get challenging, but it doesn't mean it has to go away forever. So something that someone can do at home is just simple sit to stands and again in a chair that doesn't move. So no wheels. The couch the couch is debatable. Another thing that I see often is that you know we are creatures of habit, including myself. So when it comes to an older adult, they'll be in their favorite couch and I don't blame them I would too but that couch has probably been sat in over a million times and so getting up from that worn in pouch is going to be difficult to, especially if it's a low couch. So finding a chair that is, you know, 90 degrees, 90 degree angle with your, your knees and if, for anyone who is like I don't know what that is you know just looking down and seeing if your feet and your knees are in a 90 degree angle and hip width apart. So there's a you know space between your feet about two fists and you know, and then you get up that way. So really using your legs to stand up and then encouraging that person to sit down without holding on to the handles and really using their core strength to sit down slowly. So those are. Those are like my two favorite exercises to so the balance and the sit to stands to do at home.

Parker Condit: 39:42

Yeah, that's great. I used to do a lot of sit to stands with any of the older people that I would work with, and my progression was always like if they had to use their arms to assist on the way up or down. It's like their progression or their goal eventually was to like lean forward enough to feel your abs and then hopefully be able to get to stand up. Yeah, it's been a few years since I've done that, but you start mentioning it. I'm like, oh, I used to love those. Yeah, but yeah, it's just a squat right, that's just a squat progression and it's a very normal human pattern that people need to keep doing and they do in there every day. You know, sitting down, standing up kitchen table, go to the bathroom, yeah, so it's very important to continue training those. So those are, those are great to have. Do you prescribe any like at home stretches or anything for the flexibility side of things that you can do for people who are somewhat limited?

Mercedes Fernandez: 40:33

Yes, flexibility is also a really great way to, because, again, at home you can, you can use anything. One of the ones that I recommend often is you can get a belt or some kind of like a like the belt from a robe, any kind of taught trying to find my words, but to like a belt, and you can do a range of motion with your shoulders there. So that's really going to help open the shoulders, going to open the arms, and they can just you know, can see me in the camera hold, you know, hold the belt, kind of gently, pull it apart, and then, you know, begin to do up and down, you can go side to side. There's a lot of things that you can do with that flexibility. And then for lower, lower extremities, again, you can do it sitting in that favorite couch is just extending, extending both legs one leg at a time, doing some ankle rotations, reaching slightly down and making sure that you're going slow at all times, that we're not pulling any muscles.

Parker Condit: 41:40

I don't want to get too specific because it's yeah, it's going to be difficult because it's always going to be dependent on the individual. But do you have like an approximate protocol of like you should do 10 reaches once a day, three days a week, or is it 10 reaches three times a day, seven days a week? Just trying to give people a better framework to work off of understanding. There's going to be like individual variants with all of this.

Mercedes Fernandez: 42:05

Yes, of course I. Typically my favorite protocol is the 8 to 12 rule. So for anything that's straight training you want to build strength, you do eight repetitions, three times. If it's something like flexibility or endurance, so you kind of keep that conditioning, you do 12 repetitions, again three times. When it comes to flexibility, I don't really have a set protocol. Again, like you said, every person's different. But try to stretch until it feels nice and juicy, You're like good, and sometimes, as you know, stretching can just feel a little discomfort. But once that discomfort goes away, so we'll say maybe five to 10 seconds, then you can switch and then come back to it. So three times, two to three times.

Parker Condit: 42:57

On the flexibility side, Okay, when people are kind of getting to that point of discomfort with stretching, should they be tense, should they try to relax, should they try to breathe through it? Should they inhale into it? Should they exhale into it Anything you can add to help people as they go through these?

Mercedes Fernandez: 43:13

Of course, I actually really do love stretching as well. It's like my second bread and brother. I think that when it comes to stretching, you definitely do want to feel that discomfort a little bit, but breathing is absolutely important. So, breathing into it and, like you said, breathing in and breathing out, you're breathing. You know, really. Imagine, I tell my clients, imagine breathing into that, tingling that like tautness, and then just let the breath like wash it away. Let the breath will like totally take it away. Just breathe, keep breathing and hold and don't bounce through the stretch, because a lot of the things people love to do is like keep bouncing, keep reaching, keep reaching, and if you're in kinesiology or physiotherapy world, you know that you're never supposed to bounce. So, especially when someone is just starting or warming up, we want to make sure those muscles are nice and warm so we don't pull anything. If you're in a cold stretch, you have a bigger chance of pulling a muscle and we don't want that.

Parker Condit: 44:21

Yeah, nice and slow and smooth. Smooth is very good. Can you speak to some of the issues with mobility aids, or maybe not issues, but just the common things that you see? Maybe start with walkers like how is that possibly? How is the setup wrong? What can caregivers do to look out for improper setup? Can you identify it just based on somebody's posture then, when you're watching them use it, things like that.

Mercedes Fernandez: 44:44

Absolutely the biggest thing that I see 99.9% of the time, is that the walker is always too low. So they all come in the same manufacturer setting and essentially either they're gifted this is based on research they're either gifted or acquired by a friend or family, or they're given part of the time they're given through PT. So those are semi-set up. But if they're acquired or they go to CVS like actually I think it might be time for a cane oh, this walker is on sale, okay, it's fine, I can use it shopping, et cetera, et cetera. Or someone bought them one on Amazon. All of those walkers are not set up. They're like baseline, default setting. So what you'll notice is the next time you go out and I encourage you and your listeners to just keep an eye on this is that the walkers are too low so a person will be hunched over To reach the handles. So that's like already compromised, immediately compromised in your posture, because you're you know they're looking down they're hunched over, their shoulders are too forward. And then on top of that, because the walker, if it has the most common you see in the community is a four-wheeled walker and so they have breaks in a seat and a bag. This one is. The hazard here is because they're too low. They're looking down at their feet and then they're pushing the walker too far forward, so then they're dragging their feet. It's almost like they're trying to catch up to the walker and the walker is just on its way out. So that itself is those are like the biggest things that I see, and so to correct that, you really need to bring the walker back, you have to raise the walker, and then there's you know, there's, there's protocol for that and how to set it up properly. But initially, like the baseline of all kinesiology, you want to keep those shoulders 90 degrees that's the golden number and you want to keep that walker close. So the trick is that there is a base. If you look down, you should see your feet inside the perimeter of the walker, if the seat is, if the seat is up. But even then, if you don't reach inside, your feet should not be far, far from far, behind the walker.

Parker Condit: 47:18

Yeah, now they like as you were describing that, I'm like. I think that's the only way I've ever seen somebody use a walker is sort of behind it, chasing it in their feet not necessarily between the base of the two wheels and hunched over. So, like is, like is an easier, like visual representation, like they should just be like upright, as if they were like should your arms be straight when you're holding the supports? Or just like slight bend in the elbows.

Mercedes Fernandez: 47:43

Yeah, slight bend, they should be pushing down into the handles so that. So that pushing down motion will push the walker with with the step forward. So, instead of pull, if you're, if the, if the, if your arm is straight, that's why they're pushing it forward, because their arms are straight and you know they're, they're chasing behind it. But if they bring the walker in and it's just, it's about 45 degree, 90 to 45 degree you're, you're really bringing it in and you're keeping those elbows Close to the body, was. Another thing is because they're low, their elbows are out, you know, and then again it adds to the neck tension, it adds to the shoulders in the back. So, yeah, the ideal position is to get as upright as possible.

Parker Condit: 48:31

Yep, we've all seen those posture yeah.

Mercedes Fernandez: 48:36

Yeah, it's a and it's yeah, go ahead.

Parker Condit: 48:40

Are there any considerations with canes Like? What are the common mistakes there, like should there be a padded handle? Should the like? The wooded wood canes like those just look good, but is aluminum better? Is material matter? Anything like that?

Mercedes Fernandez: 48:53

Yes, excellent question. There is a difference. So the wood cane is is very much more of a fashion statement. They're not really ideal because you can't really adjust the vote for time and those are. It's almost like the favorite shoes and the favorite couch. Those are going to be harder to take away from the from the person or switch out when they need a different cane because they're attached to it, so becomes just part of their identity. The aluminum based ones are more common, more recommended and those ones usually have like the buttons. Where you can, you can adjust. Yeah, but overall I think the difference between canes and walkers is it's just really based on stability. So canes are usually used with with an individual who has decent balance. They're not necessarily fully reliant on the cane. Again, I think it's can be more of a fashion thing, a little sense of security, like my grandfather used to cane and I can still hear it, like I could hear the cane. He didn't really use it, he just it was there. So, yeah, the thing I see the most is that the the the thing, the error, most most common error, I guess, with the cane is that they will lift the cane when they walk, which is opposite of what the cane is. The cane is, you put the cane down and then you take a step, so it's a third. It acts as your, your, an extension of your leg. So counter, counterbalance. So oftentimes they'll walk but they'll lift the cane as they're walking. Yeah, so you kind of just have to teach them the beginning.

Parker Condit: 50:46

Were there any other, like mobility tools that you see prescribed very often, that are just. There's a very obvious quick set of fixes that would just yield very positive results for the people using them.

Mercedes Fernandez: 50:58

That's a good question. I think that the two, the two that I see often are just those canes and walkers in the U? S. In Europe I have noticed that cane crutches are a lot more common, but they're not really used in the United States. If you have the sners in Europe, it's going to be the same. The cane's here, excuse me, the crutches here are almost like canes, but they're the ones that kind of clip in to the bicep or the tricep, excuse me, and then you put that forced out. So again, the thing is just making sure that they're adjusted and you're not reaching forward. So any device that you're using, wheelchairs are obviously very different. You don't need to set them up too much there. But anything that you're using for mobility, you want to ensure that it's adjusted to your height so you're not overreaching and you're not underreaching.

Parker Condit: 51:53

Okay, yeah, I was just curious if there's anything else we were really obviously missing beyond walkers and canes, but it sounds like you got this covered. So I want to go back to sort of the larger systemic issues. You know, being in Europe it's going to be a little bit different, but in the US I've heard numbers that vary anywhere from 10% to 30% of your health outcomes are actually like that's all your actual health care provider is going to contribute to. So it's a much smaller amount than you would actually expect, where your behavior, like the things that you do in your everyday life, the food you eat, how much you move that's another 20 to 30%, but like 50% of your outcomes are based on what are known as social determinants of health. Those are things that you basically can't influence. It's where you live, it's the access to green space, it's the quality of air, quality, of access to the quality foods, things like that. I don't even know how to begin addressing these issues other than just asking people about them, which feels so inadequate, but it's like the only place I know how to start. Do you have any ideas of? You know? You've been able to live in Europe so you get to see different health care systems and how they operate. But for the US, do you have any idea of like where to even begin for trying to address these social determinants of health?

Mercedes Fernandez: 53:19

It's a tricky question really, you know. I think that, like you said, where do you start? You know, and it's something that we really do need to talk about. I am originally from the West Coast of the United States and I'd like to say that, well, the community that I have lived in has access to a lot of better things, and you know different parts of the country, but generally, you know, for me, having this experience in Europe just really showed me that it is kind of all the same everywhere, no matter if you're living in California or you're living in Florida or you're living in Vermont or Texas or Washington. You know, I think it depends on, unfortunately, again, it goes back to, you know, what are those social determinants of health? Who are the low? Is it a low income population? Most generally, it's in a minority community. You know where and why are these people, these communities, these individuals not getting access to it, and even other communities that are maybe not of color, right, I think? Just low income communities, period. You know they suffer, and I think the question that comes up for me too is well, what about these more affluent communities? What about these more? I wouldn't say budget friendly, but they are more allocated to a higher class community? Do they have more parks? Are they really getting better care? You know, based on the statistics. Yes, I am a person of color. I am a mine I technically considered a person of minority. Did I have good health care growing up? Yes, I did. Did that change anything? Maybe, but I can't say for sure that I got the best quality health care either. I think for me, what goes back to it is that I personally just think that the US health care system is very murky. There are different interests and, yes, it affects these specific. It's almost, I think. The concept for me is like it's almost what they want us to think. It's almost like yeah, the low income community is people of color minorities. We're going to make sure that they're not going to have all the access, but are we really asking the question like what about the opposite side of the spectrum? Are they also getting high quality care, or is it a facade too? I know kind of going on this tangent, I guess, but yeah, I think that's where I want to start.

Parker Condit: 56:10

Yeah, no, it's a good point. I think I'll try to touch on the idea of if you are from an affluent area. One of the biggest predictors of financial success in this country is the zip code that you're born in, which you'd probably say enough. If you're just born into an affluent area, you're probably going to be fine. It's not to say you don't have to work and things like that, but that alone is a little bit indicative of some of the issues here. But I do wonder if cultural awareness from healthcare providers that's got to play a difference. I see this a lot with anyone from the Hispanic community, because a lot of those foods are sort of demonized, especially nowadays with how much people are talking about glucose and things like that like oh too much rice, it's going to spike your glucose. I think there's a lack of cultural sensitivity from the healthcare providers and, if nothing else, that's going to be somewhat dismissive of the person's experience, whether or not you get a statin or whether or not you get metformin for diabetes or prediabetes. I think the experience in the doctor's office or wherever you're going, that's going to be a contributing factor and that's probably something that doesn't get talked about enough. So whether or not the actual like what's written down in the EHR for that person's care plan, it might not differ, but I think the experience differs quite a bit.

Mercedes Fernandez: 57:38

Absolutely, absolutely. I think that you touched on a great point too. Is that again, I think that just, I'm very for me, it's subjective because I've only lived on the west side of, or the west coast of, the United States, but I like to think that all of America is very diverse and there are different cultures. Like we really are a melting pot if we zoom in and then zoom out and zoom back in. Whether we want to believe it or not, we do have so many different cultures. I myself am from the Bay Area, so I grew up with a lot of Filipinos, mexicans. There's a big Indian community population now and I think that's really amazing, and with that comes culture. So how do we integrate and make sure that not only are they getting healthcare, are they being heard, are they being understood? And I think, if anything, we can all learn from different cultures too, because I know that certain cultures, like we, can learn from the Belgians if there's a Belgian in the United States that, hey, actually cycling is really good for you and we love it and integrating that into the social determinants of health, more active communities, a safer bike path, a safer park to walk around in.

Parker Condit: 59:00

Yeah, the more I do talk to people about this fair amount and it's like there's never like a clean answer. But what does seem to be very common is the fact that it needs to start at the community level, because I talk a ton about walking. It's such a low hanging fruit, very accessible In the country. It's accessible if you live in an area that's safe to walk in and you have availability to green spaces. So it all comes down to the community level and I've actually avoided politics for so long just because I've had the privilege that I can. But I think getting involved it may seem like at the national level politics, it's so hard for an individual to drive change at that level. But at the local politics level, like getting those people to kind of make promises for your community to build better green spaces and, like you said, having having the infrastructure in place to have bike paths right. If there aren't bike paths on the road it's super dangerous to ride a bike and that largely facilitates the I guess the the actions of the people in that community. So I think it has to start at the community level. But I know nothing about community organizing and driving change at the community level, which, again, I just feel like, I feel like so impotent as far as, like, what I can do from the standpoint, but do you have any? other thoughts on this particular topic.

Mercedes Fernandez: 1:00:31

Well, I agree with you, and I think that I had a brief internship during COVID, or right, the first couple of months of COVID, in policy, and I was so determined, I was like, yes, I want change, I want to bring mental health to assisted living communities because older adults need therapy, and it was a mental health organization and I was, you know, like a little light, so excited. And then the director was like, don't get too excited, policy takes years. And so of course I didn't last very long. But to your point, I feel the same of like why it's so difficult to just create, even at the baseline of a local community policy. Right, if you, if you, I think for me, and I'm the same, I don't really, I haven't really talked much into the political aspects, but now I'm like you know what, I'm just gonna hear me roar, kind of thing, because I think that together we can make change. But it's really working towards those politicians, right? What's the incentive? Unfortunately, it always goes back to funding, to budget. You know, do people really care? Unfortunately, it's sad that we're so desensitized to shootings that we can't even change gun policy yet. Or, you know, I don't even know. I'm like so out of the loop with. I don't even know what's going to happen, but if that isn't making, if that's like making waves and still not changing, how are we implementing more greenery? How are we implementing, you know, safer community for kids walking to school, biking to school, older adults, health? I think one policy that I can think of is this is at least in California I don't know about other parts of America but you know the outdoor gyms in the park. For whatever reason, many years ago, that actually was put into place, and now you have these outdoor fitness exercise gyms In a park. The thing that hurts me the most, though, is that you know there's an instruction, there's a. You know, there's a board with instructions of like here's how to do a push up or here's how to do a pull up on this one bar that we installed, and it's like how often are people really going to stand there and read? And unless someone else is using it, then the situation's like oh, okay, there's like there's a free outdoor gym. Cool, I don't know how to use any of this, but I saw that person do it, and I'm, you know, now I'm going to go and try it.

Parker Condit: 1:03:11

So I think it's where it comes back to like community leadership, like it needs to be, people in that community who, like it's your neighbors, it's people that you can relate to, that are going to be the ones, like initiating, that be like hey, saturday mornings we're going to do a 20 minute educational, 40 minute in practice we're actually going to work out on this thing. But yeah, I think in California it also helps that you live in a place where you have you can work out outside year round, but like I live in Arizona, so it's the same thing, like I have access to be outdoors comfortably most of the year, again, it's like these are all, these are all contributing factors. Yes, so I don't know this is we didn't actually get anywhere with that topic, but I don't know. I do think talking about it at the very least, is more important than just not talking about it. So, if anyone, listening has expertise on community organization and driving community change. Feel free to reach out to, I think, either of us. Your contact information is going to be in the show notes as well, but did you have any other closing thoughts you wanted to offer before we wrap things up?

Mercedes Fernandez: 1:04:20

Yes, I think that, first of all, I think that, like we just talked about the systemic issues, the determinative health and an understanding and even just being curious about that topic is really important. So I really applaud you for bringing that up and engaging your listeners to think about that too, because, at the end of the day, I feel like we're all human. Whether we are different colors, different cultures, we are, at the end, the base humans, and so we all equality, right, getting health. So I have a family member who's in the hospital right now from a hemorrhagic stroke that came out of nowhere. And then I had someone who an elderly grandparent. She's like my third grandma. She's not a real grandma, but she was very close. She just passed away but she had a great life right. So did she if? But she didn't have access to good health care. So all of these things of whether we are elderly or we're young, we are human at the end of the day and we all deserve to have a healthy body, to stay mobile, have access and the awareness to just move right, to understand the power of movement, the benefit of movement, and if you don't want it, if you're terrified of aging and you want to age gracefully, you know. Keep that in mind now that movement is going to be your key, finding the accessibility to even. You know, even if you can't get outdoors, you can do. I don't like to call it exercise, because people are also scared of the word exercise and like no, no, no, I can't exercise, or I don't want to exercise. It's okay. Let's not call it exercise. How about? Let's just call it mobility, let's call it movement. You can do that in the comfort of your own home.

Parker Condit: 1:06:23

Very true, and I think you offered some great insights and examples of what people can do in their own home and better ways for people to help, hopefully, navigate this very tricky health care system if you are yourself involved in it or you're a caregiver and you have aging parents who are kind of going through this system right now. But that sounded like a very eloquent way to wrap this episode the fact that we are all human. I think that's something we can always at least try to find common ground over. So, mercedes, thanks so much for coming on. This is a. It was a real pleasure talking to you.

Mercedes Fernandez: 1:06:54

Thank you so much for having me.

Parker Condit: 1:06:55

Hey everyone. That's all for today's show. I want to thank you so much for stopping by and watching, especially if you've made it all the way to this point. If you'd like to be notified when new episodes are going to be released, feel free to subscribe and make sure you hit the bell button as well. To learn more about today's guest, feel free to look in the description. You can also visit the podcast website, which is exploringhealthpodcastcom. That website will also be linked in the description. As always, likes, shares, comments are a huge help to me and to this channel and to the show. So any of that you can do I would really appreciate. And again, thank you so much for watching. I'll see you next time.